Law 818 / Rev. 09-25-2017 1 IN THE COURT, EIGHTEENTH JUDICIAL CIRCUIT, BREVARD COUNTY, FLORIDA CASE NUMBER: 05 - - - -XXXX-XX PLAINTIFF CLOCK IN DEFENDANT 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 andhave 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 writingto have my wages garnished.2.Social Security benefits.3.Supplemental Security Income benefits.4.Public assistance (welfare).5.Workers222 Compensation.6.Unemployment Compensation.7.Veteran222s benefits.8.Retirement or profit-sharing benefits or pension money.9.Life insurance benefits or cash surrender value of a life insurance policy or proceeds ofannuity contract.10.Disability income benefits.11.Prepaid College Trust Fund or Medical Savings Account.12.Other exemptions as provided by law (explain) American LegalNet, Inc. www.FormsWorkFlow.com Law 818 / Rev. 09-25-2017 2 CASE NUMBER: 05 - - - -XXXX-XX CLAIM OF EXEMPTION AND REQUEST FOR HEARING I request a hearing to decide the validity of my claim. Notice of the hearing should be given to me at: Address: Telephone Number: () The statements made in this request are true to the best of my knowledge and belief. Defendant222s Signature Date STATE OF FLORIDA COUNTY OF BREVARD The foregoing instrument was acknowledged before me this day of , 20, by , who is personally known to me or who has produced , as identification and who did take an oath. My Commission Expires: Notary Public CERTIFICATE OF SERVICE I HEREBY CERTIFY that on the day of , 20, I hand-delivered mailed e-mailed couriered the foregoing to the following parties: American LegalNet, Inc. www.FormsWorkFlow.com Law 818 / Rev. 09-25-2017 3 CASE NUMBER: 05 - - - -XXXX-XX CLAIM OF EXEMPTION AND REQUEST FOR HEARING REQUEST FOR ACCOMMODATIONS BY PERSONS WITH DISABILITIES: If you are a person with disability who needs any accommodation in order to participate in this proceeding, you are entitled, at no cost to you, to the provision of certain assistance. Please contact Court Administration at the Moore Justice Center, 2825 Judge Fran Jamieson Way, 3rd Floor, Viera, FL 32940-8006, (321) 633-2171, at least 7 days before your scheduled court appearance, or immediately upon receiving this notification if the time before the scheduled appearance is less than 7 days. If you are hearing or voice impaired, call 711. American LegalNet, Inc. www.FormsWorkFlow.com