Rev. 12/09 UNITED STATES BANKRUPTCY COURT EASTERN DISTRICT OF NORTH CAROLINA Division IN RE: CASE NUMBER: DEBTOR(S) ) ) ) ) ) ) ) ) ) ) ) ) ) ) JUDGMENT CREDITOR (PLAINTIFF) VS. JUDGMENT DEBTOR (DEFENDANT) ADVERSARY PROCEEDING NUMBER: MOTION TO CLAIM EXEMPT PROPERTY I, the undersigned, move to set aside the property claimed below as exempt. 1. I am a citizen and resident of Carolina. County, North 2. [ ] I am married to [ ] I am not married. 3. I live at (I own) (I am purchasing) (I rent) (choose one; mark out the other choices) a (house) (mobile home) (apartment) (choose one; mark out the other choices). The following persons live in my household and are in substantial need of my support: NAME RELATIONSHIP TO JUDGMENT DEBTOR AGE (use initials only for minor children) American LegalNet, Inc. www.FormsWorkFlow.com 4. I (do) (do not) own any other real property. If other real property is owned, list that property on the following lines. If no other real property is owned, mark "not applicable" on the first line. 5. The following persons are, so far as I am able to tell, all of the persons or companies to whom I owe money: 6. I wish to claim my interest in the following real or personal property that I use as a residence or my dependent uses as a residence. I also wish to claim my interest in the following burial plots for myself or my dependents. I understand that my total interest claimed in the residence and burial plots may not exceed $35,000 (or, if I am unmarried and 65 years of age or older and the property was previously owned by me as a tenant by the entireties or as a joint tenant with rights of survivorship and the former co-owner is deceased, the total interest claimed may not exceed $60,000) . I understand that I am not entitled to this exemption if I take the homestead exemption provided by the constitution of North Carolina in other property. I understand that if I wish to claim more than one parcel exempt I must attach additional pages setting forth the following information for each parcel claimed exempt. Property Location: County Township Street Address Legal Description: Number by which county tax assessor identifies property Description (Attach a copy of your deed or other instrument of conveyance that describes the property and indicate here, or describe the property in as much detail as possible). Attach additional sheets if necessary. Record Owner(s): Estimated Value: Lienholders: (1) Name Current Balance Address Motion to Claim Exempt Property Page 2 of 6 Pages American LegalNet, Inc. www.FormsWorkFlow.com (2) Name Current Balance Address (3) Name Current Balance Address (4) Name Current Balance Address 7. I wish to claim the following life insurance policies whose sole beneficiaries are (my spouse) (my children) (my spouse and children) as exempt: Name of Insurer Policy Number Face Value Beneficiary(ies) 8. I wish to claim the following items of health care aid necessary for (myself) (my dependents) to work or sustain health: Item Purpose Person Using Item 9. I wish to claim the following implements, professional books, or tools (not to exceed $2,000), of my trade or the trade of my dependent. I understand that such property purchased within 90 days of this proceeding is not exempt: Item Estimated Value 10. I wish to claim the following personal property consisting of household furnishing, household goods, wearing apparel, appliances books, animals, crops or musical instruments as exempt from the claims of my creditors. I affirm, that these items of personal property are held primarily for my personal, family or household use or for such use by my dependents. I understand that I am entitled to personal property worth the sum of $5,000. I understand that I am also entitled to $1000 for each person dependent on me for support, but not to exceed $4,000 for dependents. I further understand that I am entitled to this amount after deduction from the value of the property the amount of any valid lien or purchase money security interest and that property purchased within 90 days of this proceeding is not exempt unless it was purchased to replace otherwise exempt property. Motion to Claim Exempt Property Page 3 of 6 Pages American LegalNet, Inc. www.FormsWorkFlow.com Item (or class) of Property Amount of Lien or Security Interest Location Estimated Value of Judgment Debtor's Interest 11. I wish to claim my interest in the following motor vehicle as exempt from the claims of my creditors. I understand that I am entitled to my interest in a motor vehicle worth the sum of $3,500 after deduction of the amount of any valid liens or purchase money security interest. I understand that a motor vehicle purchased within 90 days of this proceeding is not exempt unless it was purchased to replace otherwise exempt property. Make and Model of Motor Vehicle Year Name(s) of Title Owner of Record Name(s) of Lien Holder(s)of Record Estimated Value of Judgment Debtor's Interest 12. I wish to claim as exempt the following compensation which I received for the personal injury of myself or a person upon whom I was dependent for support or compensation which I received for the death of a person upon whom I was dependent for support. I understand that this compensation is not exempt from claims for funeral, legal, medical, dental, hospital or heath care charges related to the accident or injury which resulted in the payment of the compensation to me. (a) amount of compensation: (b) method of payment: lump sum or installments (If installments, state amount, frequency and duration of payments) (c) name and relationship to debtor of person(s) injured or killed giving rise to compensation: (d) location of compensation if received in lump or installments: (e) unpaid debts arising out of the injury or death giving rise to compensation: Name and Address Services Rendered Amount of Debt 13. I wish to claim the following property as exempt because I claimed residential real or personal property as exempt that is worth less than $35,000 or I made no claim for a residential exemption under section (6) above. I understand that I am entitled to $5,000 in any property only if I made no claim under section (6) above and that if I made a claim under section (6) above, that I am entitled only to the unused amount under section (6), not to exceed $5,000. I further understand that the amount of my claim under this section is after the deduction from the value of this property of the amount of any valid lien or purchase money security interests and that tangible personal property purchased within 90 Motion to Claim Exempt Property Page 4 of 6 Pages American LegalNet, Inc. www.FormsWorkFlow.com days of this proceeding is not exempt unless it was purchased to replace otherwise exempt property. PERSONAL PROPERTY: Property Location Amount of Liens or Purchase Money Security Interest Value of Judgment Debtor's Interest REAL PROPERTY (I understand that if I wish to claim more than one parcel exempt, I must attach additional pages setting forth the following information for each parcel claimed exempt): Property Location: County Township Street Address Legal Description: Number by which county tax assessor identifies property Description (Attach a copy of your deed or other instrument of conveyance that describes the property and indicate here, or describe the property in as much detail as possible). Attach additional sheets I necessary. Record Owner(s): Estimated Value: Lienholders: (1) Name Current Balance Address (2) Name Current Balance Address (3) Name Current Balance Address (4) Name Motion to Claim Exempt Property Current Balance Page 5 of 6 Pages American LegalNet, Inc. www.FormsWorkFlow.com Address 14. I wish to claim my individual retirement accounts, individual retirement annuities, and accounts established as part of a trust. List last 4 digits of account number only. Account no. Account holder Account no. Account holder Account no. Account holder Account no. Account holder 15. The following is a complete listing of all of my assets which I have not claimed as exempt under any of the preceding paragraphs: Item Location Estimated Value 16. I certify that the above statements are true and that a copy of this motion was served on the judgment creditor , (plaintiff) by [ ] delivering a copy to him personally [ ] delivering a copy to the judgment creditor's attorney [ ] depositing a copy of the motion in a postpaid addressed wrapper in a post office, addressed to the judgment creditor (plaintiff) at the address shown on the notice of rights served on me [ ] depositing a copy of the motion in a postpaid properly addressed wrapper in a post office, addressed to the judgment creditor's (plaintiff's) attorney at the following address: Dated: Signature of Judgment Debtor (Defendant) Note to Judgment Debtor: The Clerk of the U.S. Bankruptcy Court cannot fill out this form for you. If you need assistance you should talk with an attorney. Motion to Claim Exempt Property Page 6 of 6 Pages American LegalNet, Inc. www.FormsWorkFlow.com