Superior Court of the District of Columbia Civil Division Small Claims and Conciliation Branch Building B, 510 4th Street, N.W., Room 120 Washington, D.C. 20001 Telephone (202)879-1120 , Plaintiff vs. SC No. , Defendant MOTION FOR CLAIM OF EXEMPTION AND REQUEST FOR HEARING (1) Name of party filing this Motion: (2) I claim that all or part of the money, funds or income in my or my client’s bank account is exempt from garnishment because it is (check all that apply): Social Security benefits Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) Veterans’ benefits (VA) Retirement or pension Unemployment Worker’s compensation Public assistance Child support or alimony Other (see partial list of exemptions on back) Explain: (3) To the best of my knowledge the above statement is true. A court hearing is requested about whether the money, funds or income is exempt from garnishment. Printed Name of Attorney for Party or Pro Se Party Signature of Attorney for Party or Pro Se Party Address Bar Number (where applicable) Telephone Alternate Telephone THIS MOTION HAS BEEN SET FOR A HEARING IN THE SMALL CLAIMS COURTROOM NUMBER ON AT 9:00 A.M. You must appear in Court on the above date and bring with you any documents which help you prove that your money, funds or income is exempt from garnishment (such as a bank statement, Social Security, retirement or other statement of income). Be prepared to swear or affirm that the information you give is the truth. If you do not appear on the date above, your Motion will be denied. FOR COURT USE ONLY: A COPY OF THE ABOVE MOTION WAS MAILED FROM THE CLERK’S OFFICE TO: Plaintiff (or attorney where applicable) Defendant (or attorney where applicable) Name Name Address BY: Address , DEPUTY CLERK American LegalNet, Inc. www.FormsWorkFlow.com YOUR MONEY, FUNDS OR INCOME MAY BE TAKEN TO PAY A CREDITOR. PLEASE READ THIS NOTICE CAREFULLY. Please read the “Notice of Non-Wage Garnishment and Exemptions” form for an explanation of your rights. That notice is available from the court clerk’s office (address and telephone number on the front of this form). If you believe that you are entitled to an exemption, you may choose to call the judgment creditor (or the attorney if there is one) to explain that your money, funds or income is exempt and to ask the judgment creditor who won the lawsuit against you (or attorney) to release the money, funds or income. You have a right to a court hearing. You must submit a Motion for Claim of Exemption and Request for Hearing to the court to ask for a hearing. A sample form is on the front of this page. You must submit your motion with the court clerk as soon as possible, and a hearing will be scheduled no earlier than the eleventh (11th) business day after filing, plus three (3) calendar days if the motion is served by mail, unless you request a later date. If both parties agree, the court may be able to schedule a hearing on an earlier date. The clerk will mail a copy of the hearing notice to the Plaintiff and/or other parties. It will cost you $10 to file this Motion. If you cannot afford to pay this money, you should complete separate forms that ask the court to waive this fee. These forms are called “IFP” (or in forma pauperis) forms and you can get them from the court clerk’s office. Below is a partial list of exempt money, funds and income. These are only some of the most common exemptions, and there may be other exemptions available to you. These exemptions might not apply to judgments for alimony or child support. For example, if there is a judgment against you for alimony or support, you may not be able to claim that your money, funds or income is exempt. On the other hand, if you are receiving alimony or support, in most cases that money is exempt from attachment or garnishment. It may be helpful to speak with an attorney about this matter. Partial List of Exemptions Social Security retirement, Supplemental Unemployment Benefits (DC Code § 15-501) Security Income (SSI) or Social Security Alimony, support or separate maintenance* Disability Insurance (SSDI) (42 U.S.C. § 407) (DC Code § 15-501) Veterans’ Benefits (38 U.S.C. § 5301) Payments awarded by a court in a civil or Federal Civil Service Retirement benefits criminal case* (DC Code § 15-501) (5 U.S.C. § 8346) Railroad Retirement Act Benefits (45 U.S.C. Federal Civil Service Survivor Annuities § 231m) (5 U.S.C. § 8346) Longshore and Harborworker’s Compensation Disability Benefits (DC Code § 15-501) Act Benefits (33 U.S.C. § 916) Public Assistance / TANF Benefits (DC Code Black Lung Benefits (30 U.S.C. § 902 & 33 § 4-215) U.S.C. § 916) Worker’s Compensation (DC Code § 32-1517) Seaman’s or Master’s or Fisherman’s wages Payments under retirement, pension and (46 U.S.C. § 11109) annuity plans* (DC Code § 15-501) * Limitations may apply. American LegalNet, Inc. www.FormsWorkFlow.com