JGM401 State ENG Rev 8/09www.mncourts.gov/formsPage 1 of 3State of Minnesota District Court County of: Select County Judicial District: Court File Number: Case Type:Civil Creditor (first, middle, last) Debtor (first, middle, last)vs. Financial InstitutionExemption Form (Minn. Stat. 247247 550.143, subd. 3c; 551.05, subd. 1d; and 571.912, subd. 3)A. How Much Money is Protected I claim ALL of the money is being frozen by the bank is protected. I claim SOME of the money is being protected. The amount I claim is protected is B. Why The Money is ProtectedMy money is protected because I get it from one or more of the following places: (Check all that apply)Government Benefits Government benefits include, but are not limited to, the following: MFIP - Minnesota Family Investment Program MFIP Diversionary Work Program Work participation cash benefit GA - General Assistance EA - Emergency Assistance MA - Medical Assistance GAMC - General Assistance Medical Care EGA - Emergency General Assistance MSA - Minnesota Supplemental Aid MSA-EA - MSA Emergency Assistance Food Support SSI - Supplemental Security Income MinnesotaCare Medicare Part B premium payments American LegalNet, Inc. www.FormsWorkFlow.com JGM401 State ENG Rev 8/09www.mncourts.gov/formsPage 2 of 3 Medicare Part D extra help Energy or fuel assistanceThe source(s) of funding my account is the following: If the source is a type of relief based on need, list the case number and county: Case Number: County:Government benefits also include: Social Security benefits Unemployment benefits Workers' compensation Veterans benefitsIf you receive any of these government benefits, include copies of any documents you have that show you receive Social Security, unemployment, workers' compensation, or veterans benefits. I receive other assistance based on need from another source that is not on the list.(Include copies of any documents that show the source of this money.) The source of funding in my account is the following: C. EarningsALL or SOME of my earnings (wages) may also be protected. All of your earnings (wages) are protected because: I get government benefits (see list of government benefits) I currently receive other assistance based on need I have received government benefits in the last six months I was in jail or prison in the last six monthsIf you check one of these boxes above, your wages are only protected for 60 days after they are deposited in your account so you MUST send the creditor a copy of BANK STATEMENTS that show what was in your account for the 60 days right before the bank froze your money. If all of your earnings are not exempt, then some of your earnings are still protected for 20 days after they were deposited in your account. The amount protected is the larger amount of: 267 75% of your wages (after taxes are taken out); or 267 $290 (this amount represents the sum of the current federal minimum wage multiplied by 40) D. Other Exempt FundsThe money from the following are also completely protected after they are deposited in my account. American LegalNet, Inc. www.FormsWorkFlow.com JGM401 State ENG Rev 8/09www.mncourts.gov/formsPage 3 of 3 An accident, disability, or retirement pension or annuity Payments to me from a life insurance policy Earnings of my child who is under 18 years of age Child support Money paid to me from a claim for damage or destruction of property (propertyincludes household goods, farm tools or machinery, tools for my job, business equipment, a mobile home, a car, a musical instrument, a pew or burial lot, clothes, furniture, or appliances) Death benefits paid to meI give my permission to any agency that has given me cash benefits to give information about my benefits to the above-named creditor, or its attorney. The information will ONLY concern whether I get benefits or not, or whether I have gotten them in the past six months. If I was an inmate in the last six months, I give my permission to the correctional institution to tell the above-named creditor that I was an inmate there. You must sign and send this form back to the creditor's attorney (or to the creditor, if no attorney) and the bank. Remember to include a copy of your bank statements for the past 60 days. Fill in the blanks below and go back to the instructions to make sure you do it correctly. I have mailed or delivered a copy of this form to the creditor or creditor's attorney if represented at the address listed below. Name of creditor or creditor's attorney Address of creditor or creditor's attorney I have also mailed or delivered a copy of this exemption form to my bank at the address listed below: Address of Bank/Financial Institution Dated: Signature/s/ Debtor's Name: Address: City/State/Zip: Telephone: American LegalNet, Inc. www.FormsWorkFlow.com