Local Form No. 2 Rev. 9/97 UNITED STATES BANKRUPTCY COURT EASTERN DISTRICT OF NORTH CAROLINA DIVISION IN THE MATTER OF: CASE NUMBER: Debtor(s) SCHEDULE C - PROPERTY CLAIMED AS EXEMPT I, , claim the following property as exempt pursuant to 11 U.S.C. 522(b)(2)(A) and (B) and the laws of the State ofNorth Carolina, and nonbankruptcy Federal law: 1. NCGS 1C-1601(a)(1) (NC Const., Article X, Section 2) REAL OR PERSONAL PROPERTY USED AS A RESIDENCE OR BURIAL PLOT (exemption not to exceed $10,000) Description of Property Market Mortgage Holder Amount of Mortgage Netand Address Value or Lien Holder or Lien Value VALUE OF REAL ESTATE CLAIMED AS EXEMPT: $ .00 2. NCGS 1C-1601(A)(3) MOTOR VEHICLE (exemption in one vehicle not to exceed $1,500) Model, Year Market Lien Amount Net Style of Auto Value Holder of Lien Value VALUE OF MOTOR VEHICLE CLAIMED AS EXEMPT: $ .00 3. NCGS 1C-1601(a)(4) (NC Const., Article X, Section 1) PERSONAL OR HOUSEHOLD GOODS (net value not to exceed $3,500 plus $750 forfirst four dependents). The number of dependents for exemption purposes is . Description of Market Lien Amount Net Property Value Holder of Lien Value Clothing & personal Kitchen appliances Stove Refrigerator Freezer Washing machine Dryer China Silver Jewelry Living room furniture Den furniture Bedroom furniture Dining room furniture Lawn furniture Television ( )Stereo ( )Radio ( )VCR ( )Video Camera Musical Instruments ( )Piano ( )Organ Air conditioner Paintings/Art Lawn mower Yard tools Crops Recreational equipment VALUE CLAIMED AS EXEMPT: $ .00>>>> 2 4. NCGS 1C-1601(a)(5) TOOLS OF TRADE (total net value not to exceed $750 in value). Market Lien Amount Net Description Value Holder of Lien Value (attach additional sheets if necessary) VALUE CLAIMED AS EXEMPT: $ .00 5. NCGS 1C-1601(a)(6) LIFE INSURANCE (NC Const., Article X, Section 5) Cash Description Insured Policy Number Beneficiary Value 6. NCGS 1C-1601(a)(7) PROFESSIONALLY PRESCRIBED HEALTH AIDS (Debtor or Debtors Dependents, no limit on value). Description 7. NCGS 1C-1601(a)(8) COMPENSATION FOR PERSONAL INJURY OR DEATH OF A PERSON UPON WHOM THE DEBTOR WAS DEPENDENT FOR SUPPORT. COMPENSATION NOT EXEMPT FROM RELATED LEGAL, HEALTH OR FUNERAL EXPENSE. 8. NCGS 1C-1601(a)(2) ANY PROPERTY (total net value not to exceed $3,500 less any amount used under NCGS 1C-1601(1). Description of Market Lien Amount Net of Property & Address Value Holder of Lien Value 9. NCGS 1C-1601(a)(9) INDIVIDUAL RETIREMENT ACCOUNTS as described in Section 408(a) of the Internal Revenue Code, individualretirement annuities as described in Section 408(b) of the Internal Revenue Code, and accounts established as part of a trust described in Section 408(c) ofthe Internal Revenue Code. For purposes of this subdivision, "Internal Revenue Code" means Code as defined in G.S. 105-228.90. 10. TENANCY BY THE ENTIRETY. The following property is claimed as exempt pursuant to 11 U.S.C. 522(b)(2)(B) and the law of the State ofNorth Carolina pertaining to property held as tenants by the entirety. Description of Market Lien Amount Net Property & Address Value Holder of Lien Value 11. NORTH CAROLINA PENSION FUND EXEMPTIONS a. North Carolina Local Government Employees Retirement benefits NCGS 128-31 b. North Carolina Teachers and State Employees Retirement benefits NCGS 135-9 c. Firemens Relief Fund pensions NCGS 58-86-90 d. Fraternal Benefit Society benefits NCGS 58-24-85 e. Benefits under the Supplemental Retirement Income Plan for teachers and state employees are exempt from levy, sale, and garnishment NCGS 135-95 f. Benefits under the Supplemental Retirement Income Plan for state law enforcement officers are exempt from levy, sale, and garnishment NCGS 143-166.30(g) VALUE OF ENTIRETIES PROPERTY CLAIMED AS EXEMPT $ .00 12. OTHER EXEMPTIONS CLAIMED UNDER LAWS OF THE STATE OF NORTH CAROLINA: a. Aid to the Aged, Disabled and Families with Dependent Children NCGS 108A-36 b. Aid to the Blind NCGS 111-18 c. Yearly Allowance of Surviving Spouse NCGS 30-15 d. Workers Compensation benefits NCGS 97-21 Schedule C - Property Claimed as Exempt Page 2 of 4 Pages>>>> 3e. Unemployment benefits, so long as not commingled and except for debts for necessities purchased while unemployed NCGS 96-17 f. Group insurance proceeds NCGS 58-58-165 g. Partnership property, except on a claim against the partnership NCGS 59-55 h. Wages of debtor necessary for support of family NCGS 1-362 i. Benefits under the Separate Insurance Benefits Plan for state and local law enforcement officers are exempt from levy, sale, and garnishment NCGS 143-166.60(h) j. Vested benefits under the North Carolina Public Employee Deferred Compensation Plan are exempt from levy, sale, and garnishment NCGS 147-9.4 TOTAL PROPERTY CLAIMED AS EXEMPT $ .00 13. FEDERAL PENSION FUND EXEMPTIONS a. Foreign Service Retirement and Disability Payments 22 U.S.C. 4060 b. Civil Service Retirement benefits 5 U.S.C. 8346 c. Railroad Retirement Act annuities and pensions 45 U.S.C. 231m d. Veterans benefits 38 U.S.C. 5301 e. Special pension paid to winners of Congressional Medal of Honor 38 U.S.C. 1562 f. Annuities payable for service in the General Accounting Office 31 U.S.C. 776. 14. OTHER EXEMPTIONS CLAIMED UNDER NONBANKRUPTCY FEDERAL LAW: a. Social Security benefits 42 U.S.C. 407 b. Injury or death compensation payments from war risk hazards 42 U.S.C. 1717 c. Wages owing a master or seamen, except for support of a spouse and/or minor children 46 U.S.C. 11109 d. Longshoremen and Harbor Workers Compensation Act death and disability benefits 33 U.S.C. 916 e. Crop insurance proceeds 7 U.S.C. 1509 f. Public safety officers death benefits 42 U.S.C. 3796. See subsection (g). g. Railroad unemployment insurance 45 U.S.C. 352. See subsection (e). VALUE OF PROPERTY CLAIMED AS EXEMPT: $ .00 15. The following tangible personal property was purchased by the debtor within ninety (90) days of the filing of the bankruptcy petition: Market Lien Amount Net Description Value Holder of Lien Value 16. The debtors property is subject to the following claims: a. Of the United States or its agencies as provided by federal law. b. Of the State of North Carolina or its subdivisions for taxes, appearance bonds or fiduciary bonds; c. Of a lien by a laborer for work done and performed for the person claiming the exemption. but only as to the specific property affected.d. Of a lien by a mechanic for work done on the premises, but only as to t