IN THE COURT, EIGHTEENTH JUDICIAL CIRCUIT, BREVARD COUNTY, FLORIDA HEAD OF HOUSEHOLD AFFIDAVIT CASE NUMBER: 05 - XXXX-XX PLAINTIFF CLOCK IN DEFENDANT BAR CODE GARNISHEE I, being a resident of Brevard County, Florida, do affirm that I am the HEAD OF HOUSEHOLD, per F. S. CHAPTER 222.11, and have the follow ing dependants: SPOUSE: CHILD: CHILD: CHILD: CHILD: AGE: AGE: AGE: AGE: AGE: I now motion the court for an Order to dissolve the pending garnishment, per F. S. Chapter 222.11, and to release the funds held by . Name Address City/State/Zip Telephone Number CC: Plaintiff Garnishee day of , 20 . SO SWORN to and acknow ledged before me this Notary Public or Deputy Clerk Law 593 Rev. 11-14-2012 American LegalNet, Inc. www.FormsWorkFlow.com