"Claim of Exemption and Request for Hearing" - Florida

Claim of Exemption and Request for Hearing is a legal document that was released by the Florida Department of Juvenile Justice - a government authority operating within Florida.

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Download "Claim of Exemption and Request for Hearing" - Florida

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IN THE COUNTY COURT OF THE
JUDICIAL
CIRCUIT IN AND FOR
COUNTY, FLORIDA
Plaintiff
Case No.:
Vs.
Defendant
And
STATE OF FLORIDA DEPARTMENT OF JUVENILE JUSTICE,
Garnishee_______________________________/
CLAIM OF EXEMPTION AND REQUEST FOR HEARING
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 or less per week.
_____ b. I provide more than one-half of the support for a child or other
dependent, have net earnings of more than $750 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. Workers’ Compensation.
_____ 6. Unemployment Compensation.
_____ 7. Veterans’ benefits.
_____ 8. Retirement or profit-sharing benefits or pension money.
_____ 9. Life insurance benefits or case surrender value of a life insurance policy or
proceeds of annuity contract.
IN THE COUNTY COURT OF THE
JUDICIAL
CIRCUIT IN AND FOR
COUNTY, FLORIDA
Plaintiff
Case No.:
Vs.
Defendant
And
STATE OF FLORIDA DEPARTMENT OF JUVENILE JUSTICE,
Garnishee_______________________________/
CLAIM OF EXEMPTION AND REQUEST FOR HEARING
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 or less per week.
_____ b. I provide more than one-half of the support for a child or other
dependent, have net earnings of more than $750 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. Workers’ Compensation.
_____ 6. Unemployment Compensation.
_____ 7. Veterans’ benefits.
_____ 8. Retirement or profit-sharing benefits or pension money.
_____ 9. Life insurance benefits or case surrender value of a life insurance policy or
proceeds of annuity contract.
_____ 10. Disability income benefits.
_____ 11. Prepaid College Trust Fund or Medical Savings Accounts.
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: __________________________________________________________________
The statements made in this request are true to the best of my knowledge and belief. A copy of
this Claim for Exemption has been [ ] hand delivered or [ ] mailed to the plaintiff or plaintiff’s
attorney this ________ day of ____________________, 20__.
________________________ ___________________________________________________
Defendant’s Signature
Date
STATE OF FLORIDA
:
COUNTY OF
:
Sworn and subscribed to before me this ________ day of ____________________,
20__, by _____________________________________who is personally known to me or who
has produced _____________________________________as identification and who did
[ ]
did not [ ] take an oath.
______________________________________
Notary Public
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