IN THE UNITED STATES DISTRICT COURT FOR THE WESTERN DISTRICT OF PENNSYLVANIA Plaintiff vs . Defendant 1 1 1 1 1 1 Miscellaneous No. Civil Action No. To the United States Marshal: I, the above-named defendant claim exception of property from levy or attachment: (1) From my real or personal property in my possession which has been levied upon, I claim the following exemption (specify the property and basis for exemption) : (2) From my property which is in the possession of a third party, I claim the following exceptions. (a) Social Security benefits on deposit in the amount of $ I (b) Other (specify amount and basis of exemption): I request a prompt court hearing to determine the exemption. Notice of the hearing should be given to me at: (ADDRESS) ( TELEPHONE NO. ) American LegalNet, Inc. www.FormsWorkFlow.com I verify that the statements made in this Claim for Exemption are true and correct. I understand that false statements herein are made subject to penalties of 18 U.S.C. §I001 relating to unsworn falsification to authorities. DATE: DEFENDANT: THIS CLAIM TO BE FILED WITH THE OFFICE OF THE UNITED STATES MARSHAL WESTERN DISTRICT OF PENNSYLVANIA 241 U.S. Post Office and Courthouse Pittsburgh, PA 15219 (412)644-3351 American LegalNet, Inc. www.FormsWorkFlow.com