Joseph E. Smith Clerk of the Circuit Court St. Lucie County, Florida County Civil division 250 N.W. Country Club Drive Port Saint Lucie, Florida 34986 (772) 785-5880 In the County Court, Nineteenth Judicial Circuit, in and for County of St. Lucie, State of Florida ­ Civil Division Case No. ___________________________________________ PLAINTIFF VS ____________________________________________ DEFENDANT. CLAIM OF EXEMPTION AND REQUEST FOR HEARING I claim exemption from garnishment under the following categories as checked: ______ 1. Head of family wages. (Check either a. or b. below, if applicable) ______ a. I provide more than one-half of the support for a child or other dependent and have 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 or more than $750. 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. Workers' Compensation ______ 6. Reemployment assistance or unemployment compensation ______ 7. Veterans' 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 hearing should be given to me at: Address:________________________________________________________________________________________ Telephone number: _____________________________________________________________________________ I CERTIFY UNDER OATH AND PENALTY OF PERJURY that a copy of this CLAIM OF EXEMPTION AND REQUEST FOR HEARING has been furnished by (circle one) United States mail or hand delivery on __________________, 20_____, to: (insert names and addresses of Plaintiff or Plaintiff's attorney and of Garnishee or Garnishee's attorney to whom this document was furnished) ____________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ I FURTHER CERTIFY UNDER OATH AND PENALTY OF PERJURY that the statements made in this request are true to the best of my knowledge and belief. _________________________________________ DEFENDANT'S SIGNATURE __________________________________ DATE STATE OF FLORIDA COUNTY OF ________________ Sworn and subscribed to before me this _______ day of ___________________________________, 20_____. _________________________________________ Notary Public / Deputy Clerk Personally know ____ or produced identification ____ Type of Identification produced ________________ Updated 07/01/2013 American LegalNet, Inc. www.FormsWorkFlow.com By:_______________________________________