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Motion To Claim Exempt Property Form. This is a North Carolina form and can be use in USBC Eastern Federal.
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Tags: Motion To Claim Exempt Property, North Carolina Federal, USBC Eastern
Rev. 12/09
UNITED STATES BANKRUPTCY COURT
EASTERN DISTRICT OF NORTH CAROLINA
Division
IN RE:
CASE NUMBER:
DEBTOR(S)
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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)
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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
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(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
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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
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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
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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
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