CIVIL COUNTY OF COURT OF THE CITY OF NEW YORK Index No. ________________ Plaintiff(s), EXEMPTION NOTICE as Required by New York Law [CPLR § 5222(a)] -against- Defendant(s). YOUR BANK ACCOUNT IS RESTRAINED OR “FROZEN” The attached Restraining Notice or Notice of Levy by Execution has been issued against your bank account. You are receiving this notice because a creditor has obtained a money judgment against you, and one or more of your bank accounts has been restrained to pay the judgment. A money judgment is a court's decision that you owe money to a creditor. You should be aware that FUTURE DEPOSITS into your account(s) might also be restrained if you do not respond to this notice. You may be able to “vacate” (remove) the judgment. If the judgment is vacated, your bank account will be released. Consult an attorney (including free legal services) or visit the court clerk for more information about how to do this. Under state and federal law, certain types of funds cannot be taken from your bank account to pay a judgment. Such money is said to be “exempt.” DOES YOUR BANK ACCOUNT CONTAIN ANY OF THE FOLLOWING TYPES OF FUNDS? 11. Social security; 12. Social security disability (SSD); 13. Supplemental security income (SSI); 14. Public assistance (welfare); 15. Income earned while receiving SSI or public assistance; 16. Veterans benefits; 17. Unemployment insurance; 18. Payments from pensions and retirement accounts; 19. Disability benefits; 10. Income earned in the last 60 days (90% of which is exempt); 11. Workers’ compensation benefits; 12. Child support; 13. Spousal support or maintenance (alimony); 14. Railroad retirement; and/or 15. Black lung benefits. If YES, you can claim that your money is exempt and cannot be taken. American LegalNet, Inc. www.FormsWorkFlow.com To make the claim, you must (a) complete the EXEMPTION CLAIM FORM attached; (b) deliver or mail the form to the bank with the restrained or “frozen” account; and (c) deliver or mail the form to the creditor or its attorney at the address listed on the form. You must send the forms within 20 DAYS of the postmarked date on the envelope holding this notice. You may be able to get your account released faster if you send to the creditor or its attorney written proof that your money is exempt. Proof can include an award letter from the government, an annual statement from your pension, pay stubs, copies of checks, bank records showing the last two months of account activity, or other papers showing that the money in your bank account is exempt. If you send the creditor’s attorney proof that the money in your account is exempt, the attorney must release that money within seven days. You do not need an attorney to make an exemption claim using the form. Dated: Creditor or Attorney(s) for Judgment Creditor Post Office Address: American LegalNet, Inc. www.FormsWorkFlow.com CIVIL COUNTY OF COURT OF THE CITY OF NEW YORK Index No. ________________ Plaintiff()s/Petitioner(s)/Claimant(s), EXEMPTION CLAIM FORM V. Defendant(s)/Respondent(s). NAME AND ADDRESS OF JUDGMENT CREDITOR OR ATTORNEY (To be completed by judgment creditor or attorney) ADDRESS A ________________________ ____________________________________ ____________________________________ NAME AND ADDRESS OF FINANCIAL INSTITUTION (To be completed by judgment creditor or attorney) ADDRESS B ________________________ ____________________________________ ____________________________________ Directions: To claim that some or all of the funds in your account are exempt, complete both copies of this form, and make one copy for yourself. Mail or deliver one form to ADDRESS A and one form to ADDRESS B within twenty days of the date on the envelope holding this notice. **If you have any documents, such as an award letter, an annual statement from your pension, paystubs, copies of checks or bank records showing the last two months of account activity, include copies of the documents with this form. Your account may be released more quickly. I state that my account contains the following type(s) of funds (check all that apply): ____ Social security ____ Social security disability (SSD) ____ Supplemental security income (SSI) ____ Public assistance ____ Wages while receiving SSI or public assistance ____ Veterans benefits ____ Unemployment insurance ____ Payments from pensions and retirement accounts ____ Income earned in the last 60 days (90% of which is exempt) ____ Child support ____ Spousal support or maintenance (alimony) ____ Workers’ compensation ____ Railroad retirement or black lung benefits ____ Other (describe exemption): American LegalNet, Inc. www.FormsWorkFlow.com I request that any correspondence to me regarding my claim be sent to the following address: (FILL IN YOUR COMPLETE ADDRESS) I certify under penalty of perjury that the statement above is true to the best of my knowledge and belief. Date Signature of Judgment Debtor American LegalNet, Inc. www.FormsWorkFlow.com CIVIL COUNTY OF COURT OF THE CITY OF NEW YORK Index No. ________________ Plaintiff()s/Petitioner(s)/Claimant(s), EXEMPTION CLAIM FORM V. Defendant(s)/Respondent(s). NAME AND ADDRESS OF JUDGMENT CREDITOR OR ATTORNEY (To be completed by judgment creditor or attorney) ADDRESS A ________________________ ____________________________________ ____________________________________ NAME AND ADDRESS OF FINANCIAL INSTITUTION (To be completed by judgment creditor or attorney) ADDRESS B ________________________ ____________________________________ ____________________________________ Directions: To claim that some or all of the funds in your account are exempt, complete both copies of this form, and make one copy for yourself. Mail or deliver one form to ADDRESS A and one form to ADDRESS B within twenty days of the date on the envelope holding this notice. **If you have any documents, such as an award letter, an annual statement from your pension, paystubs, copies of checks or bank records showing the last two months of account activity, include copies of the documents with this form. Your account may be released more quickly. I state that my account contains the following type(s) of funds (check all that apply): ____ Social security ____ Social security disability (SSD) ____ Supplemental security income (SSI) ____ Public assistance ____ Wages while receiving SSI or public assistance ____ Veterans benefits ____ Unemployment insurance ____ Payments from pensions and retirement accounts ____ Income earned in the last 60 days (90% of which is exempt) ____ Child support ____ Spousal support or maintenance (alimony) ____ Workers’ compensation ____ Railroad retirement or black lung benefits ____ Other (describe exemption): American LegalNet, Inc. www.FormsWorkFlow.com I request that any correspondence to me regarding my claim be sent to the following address: (FILL IN YOUR COMPLETE ADDRESS) I certify under penalty of perjury that the statement above is true to the best of my knowledge and belief. Date Signature of Judgment Debtor American LegalNet, Inc. www.FormsWorkFlow.com