This form is approved by the Illinois Supreme Court and is required to be accepted in all Illinois Circuit Courts. SC - EM 3103.1 Page 1 of 1 ( 03 / 18 ) STATE OF ILLINOIS , EMERGENCY MOTION TO CLAIM EXEMPTION For Court Use Only CIRCUIT COURT COUNTY Instructions Enter above the county name where the Citation to Discover Assets to Debtor's Bank was filed. Plaintiff ( First, middle, last name ) v. Fill in the rest of the information by copying it from the Citation . Defendant ( First, middle, last name ) Case Number Respondent ( Bank222s n ame ) 1. I am the d ebtor . In 2, enter the name of your bank. 2. My accounts at have been frozen. Name of b ank In 3, check all that apply. 3. My accounts contain money from the following sources : (check all that apply) Social Security , SSI benefits , and disability Pension and retirement benefits and refunds Public assistance benefits Child support Unemployment compensation benefits Workers222 compensation benefits Veterans222 benefits Circuit breaker property tax relief benefits Any other source, u p to $4,000 ("wildcard exemption") 4. This money is exempt under these laws: 42 USC 247 407(a) ; 735 ILCS 5/12 - 1001 ; and 735 ILCS 5/12 - 1006 . In 5, enter the amount of money you are claiming as exempt. 5. I claim $ as exempt. Amount of m oney in a ccount I ask for the following : Declare my funds to be exempt. Order the b ank to remove the hold on my accounts. Dismiss the Citation to Discover Assets t o a Debtor's Bank . Grant any other relief that is fair . Under the Code of Civil Procedure, 735 ILCS 5/1-109 , making a statement on this form that you know to be false is perjury, a Class 3 Felony. I certify that everything in the Emergency Motion to Claim Exemption is true and correct. I understand that making a false statement on this form is perjury and has penalties provided by law under 735 ILCS 5/1 - 109 . /s/ Your Signature Street Address If you are completing this form on a computer, sign your name by typing it. If you are completing it by hand, sign and print your name. Your Name City, State, ZIP Telephone American LegalNet, Inc. www.FormsWorkFlow.com