IN THE CIRCUIT COURT OF THE ELEVENTH JUDICIAL CIRCUIT IN AND FOR MIAMI-DADE COUNTY, FLORIDA IN THE COUNTY COURT IN AND FOR MIAMI-DADE COUNTY, FLORIDA. DIVISION CASE NUMBER CLAIM OF EXEMPTION AND REQUEST FOR HEARING CIVIL OTHER (AFEG) PLAINTIFF(S) CLOCK IN VS. DEFENDANT(S) 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 dependant and have net earnings of $750.00 or less per week. b. I provide more than one-half of the support for a child or other dependant, have net earnings of more than $750.00 a 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. Veteran’s 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 of annuity contract. 10. Disability income benefits. 11. Prepaid College Trust Fund or Medical Savings Account. 12. 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 Number: _______________________________. The statements made in this request are true to the best of my knowledge and belief. _______________________________________ Defendant’s Signature ___________________________ Date 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 did / did not take an oath. SWORN TO AND SUBSRCIBED BEFORE ME this ________ day of __________________________________, 20______. NOTARY PUBLIC, STAMP HARVEY RUVIN CLERK OF COURTS BY: __________________________________ (COURT SEAL) DEPUTY CLERK / NOTARY PUBLIC Important - See Reverse CLK/CT 862 Rev. 03/11 Clerk’s web address: www.miami-dadeclerk.com American LegalNet, Inc. www.FormsWorkFlow.com NOTICE TO DEFENDANT OF RIGHT AGAINST GARNISHMENT OF WAGES, MONEY , AND OTHER PROPERTY The writ Garnishment delivered to you with this Notice means that wages, money, and other property belonging to you have been garnished to pay a court judgment against you. HOWEVER, YOU MAY BE ABLE TO KEEP OR RECOVER YOUR WAGES, MONEY, OR PROPERTY. READ THIS NOTICE CAREFULLY. State and federal laws provide that certain wages, money, and property, even if deposited in a bank, savings and loan, or credit union, may not be taken to pay certain types of court judgments. Such wages, money and property are exempt from garnishment. The major exemptions are listed on the form for Claim of Exemption and Request for Hearing. This list does not include all possible exemptions. You should consult a lawyer for specific advice. TO KEEP YOUR WAGES, MONEY, AND OTHER PROPERTY FROM BEING GARNISHED, OR TO GET BACK ANYTHING ALREADY TAKEN, YOU MUST COMPLETE A FORM FOR CLAIM OF EXEMPTION AND REQUEST FOR HEARING AS SET FORTH ON THE REVERSE AND HAVE THE FORM NOTARIZED. YOU MUST FILE THE FORM WITH THE CLERK’S OFFICE WITHIN 20 DAYS AFTER THE DATE YOU RECEIVE THIS NOTICE OR YOU MAY LOSE IMPORTANT RIGHTS. YOU MUST ALSO MAIL OR DELIVER A COPY OF THIS FORM TO THE PLAINTIFF AND THE GARNISHEE AT THE ADDRESSES LISTED ON THE WRIT OF GARNISHMENT. If you request a hearing, it will be held as soon as possible after your request is received by the court. The plaintiff must file any objection within 3 business days if you hand delivered to the plaintiff a copy of the form for Claim of Exemption and Request for Hearing or, alternatively, 8 business days if you mailed a copy of the form for claim and request to the plaintiff. If the plaintiff files an objection to your Claim of Exemption and Request for Hearing, you will be notified of the time and date of the hearing. You may attend the hearing with or without an attorney. If the plaintiff fails to file an objection, no hearing is required, the writ of garnishment will be dissolved and your wages, money, or property will be released. YOU SHOULD FILE THE FORM FOR CLAIM OF EXEMPTION IMMEDIATELY TO KEEP YOUR WAGES, MONEY, OR PROPERTY FROM BEING APPLIED TO THE COURT JUDGMENT. THE CLERK CANNOT GIVE YOU LEGAL ADVICE. IF YOU NEED LEGAL ASSISTANCE YOU SHOULD SEE A LAWYER. IF YOU CAN’T AFFORD A PRIVATE LAWYER, LEGAL SERVICES MAY BE AVAILABLE. CONTACT MIAMI-DADE BAR ASSOCIATION 305-371-2220; THE FLORIDA BAR ATTORNEY REFERRAL SERVICE 1-800-3428011; THE PUT SOMETHNG BACK PROGRAM 305-579-5733; OR LEGAL SERVICES OF GREATER MIAMI 305-576-0080. AMERICANS WITH DISABILITIES ACT OF 1990 ADA NOTICE If you are a person with a 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 the Eleventh Judicial Circuit Court’s ADA Coordinator, Lawson E. Thomas Courthouse Center, 175 NW 1st Ave., Suite 2702, Miami, FL 33128, Telephone (305) 349-7175; TDD (305) 349-7174, Fax (305) 3497355 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. Note: The form “Affidavit of Service by Defendant Pursuant to F.S. 77.041 (3) and Request for Clerk to Dissolve “Writ” can be obtained from the Clerk’s Office Important - See Reverse CLK/CT 862 Rev. 03/11 Clerk’s web address: www.miami-dadeclerk.com American LegalNet, Inc. www.FormsWorkFlow.com