Claim Of Exemption And Request For Hearing {CTCIV228-COCIV77}

IN THE CIRCUIT/COUNTY COURT OF SIXTH JUDICIAL CIRCUIT IN AND FOR PINELLAS COUNTY FLORIDA UCN: ______________________________ Reference No.: ______________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ and vs. Plaintiff(s), Defendant(s). Garnishee. CLAIM OF EXEMPTION AND REQUEST FOR HEARING PURSUANT TO F.S. 77.041 I claim exemptions from garnishment under the following categories as checked. ______ 1. Head of family wages. (You must check a or b below.) ______ (a). I provide more than one-half of the support for a child or other dependent and have net earnings of $750.00 or less per week. ______ (b). I provide more than one-half of the support for a child or other dependent, and have net earnings of more than $750.00 per week but have not agreed in writing to have my wages garnished. ______ 2. Social Security Benefits. ______ 3. Supplemental Security Income Benefits. ______ 4. Public Assistance (welfare). ______ 5. Worker's Compensation. ______ 6. Unemployment Compensation. ______ 7. Veterans' Benefits. ______ 8. Retirement or profit-sharing benefits or pension money. ______ 9. Life insurance benefits or cash surrender value of an insurance policy or proceeds of annuity contract. ______ 10. Disability income benefits. ______ 11. Prepaid College Trust Fund or Medical Savings Account. ______ 12. Other exemptions as provided by law. (explain). _____________________________________________ I request a hearing to decide the validity of my claim. Notice of the hearing should be given to me at: Address: __________________________________________________________________________________________________ Telephone Number: _______________________________ I CERTIFY UNDER OATH AND PENALTY OF PERJURY that a copy of this CLAIM OF EXEMPTION AND REQUEST FOR HEARING has been furnished by (check one) United States mail or hand delivery on the _________ day of __________________________, 20______, to:______________________________________________________________ ______________________________________________________________________________________________________________________. (names and addresses of Plaintiff or Plaintiff's attorney and of Garnishee or Garnishee's attorney to whom this document was furnished) I FURTHER CERTIFY UNDER OATH AND PENALTY OF PERJURY that the statements made in this request are true to the best of my knowledge and belief. Defendant's signature _____________________________________________ _____________________________________________ Date STATE OF FLORIDA COUNTY OF PINELLAS Sworn and subscribed to before me this ______ day of ___________________ , by ___________________________________________ Defendant Name Signature of Notary Public - State of Florida _____________________________________________________________________ Print, Type or Stamp Commissioned Name of Notary Public _________________________________________________________ Type of identification produced _________________ Personally known _________________ or produced identification _________________ CTCIV228/COCIV77 (Rev. 2/16) American LegalNet, Inc. www.FormsWorkFlow.com