IN THE CIRCUIT/COUNTY COURT, PINELLAS COUNTY, FLORIDA CIVIL DIVISION UCN: ______________________________ Reference No.: ______________________________ __________________________________________ __________________________________________ Plaintiff(s), vs. __________________________________________ __________________________________________ Defendant(s). and __________________________________________ __________________________________________ Garnishee. CLAIM OF EXEMPTION AND REQUEST FOR HEARING PURSUANT TO F.S. 77.041 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 and have net earnings of $500.00 or less per week. ______ (b). I provide more than one-half of the support for a child or other dependent, and have net earnings of more than $500.00 per 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. Worker’s Compensation. ______ 6. Unemployment Compensation. ______ 7. Veterans’ Benefits. ______ 8. Retirement or profit-sharing benefits or pension money. ______ 9. Life insurance benefits or cash surrender value of an 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 _____________________________________________ _____________________________________________ Address _____________________________________________ Date STATE OF FLORIDA COUNTY OF PINELLAS Sworn and subscribed to before me this ______ day of ___________________ , by ___________________________________________ Notary Public/Deputy Clerk Signature of Notary Public - State of Florida _____________________________________________________________________ Print, Type or Stamp Commissioned Name of Notary Public _________________________________________________________ Type of identification produced _________________ Personally known _________________ or produced identification _________________ Certificate of Service I hereby certify that a copy of the foregoing has been mailed / hand delivered to the Plaintiff _______________________________________________________ this __________ day of ____________________________ , 20______ . Name _______________________________________________________ Signature CTCIV228/COCIV77 (Rev. 8/04) American LegalNet, Inc. www.USCourtForms.com CTCIV228 8/04