: IN THE COURT OF COMMON PLEAS : DAUPHIN COUNTY, PENNSYLVANIA : : : : NO. : : : : Plaintiff(s) V. Defendant(s) CLAIM FOR EXEMPTION FROM WAGE ATTACHMENT Notice This claim for Exemption must be filed with the Prothonotary of the Court within 30 days of service upon you of the Notice of Intent to Attach Wages. To the Prothonotary: I, the above-named Defendant, claim exemption of my wages, salary or commissions from attachment on the following ground: My net monthly income is below the poverty income guidelines as provided by the Federal Department of Health and Human Services. OR The amount of wages to be attached would place my net income below the poverty income guidelines as provided annually by the Federal Department of Health and Human Services. I have dependents. (Number) My net monthly income is $ . (Net monthly income is your total monthly wages less (1) any support payments made to the court, (2) federal, state and local income taxes, (3) F.I.C.A. payments and nonvoluntary retirement payments. (4) union dues and (5) health insurance premiums.) I certify that the statements made in this Claim for Exemption are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S.§ 4904 relating to unsworn falsification to authorities. Date: Defendant This claim shall be delivered to: Office of the Prothonotary Court of Common Pleas Front & Market Streets Harrisburg, PA. 17101 717-780-6520 American LegalNet, Inc. www.USCourtForms.com