Claim of Exemption Sample Form

by Robin from Ocala, Florida, Marion County

What type of form is required to file an affidavit for exemption of personal property from levy from civil judgment?


I am interested in filing an affidavit for exemption of personal property but am unable to locate the form.

Please advise if there is a website where I can download or locate this form.

Answer to Florida Civil Law Question

Dear Robin,

Pursuant to Florida Statutes - 77.041. Notice to individual defendant for claim of exemption from garnishment; procedure for hearing.--

To keep your wages, money, and other property from being garnished, or to get back anything already taken, you must complete a form for Claim of Exemption and Request for Hearing as set forth below and have the form notarized.

You must file the form with the Clerk's office within 20 days after the date you receive this notice or you may lose important rights.

You must also mail or deliver a copy of this form to the Plaintiff and the Garnishee at the addresses listed in the Writ of Garnishment.

You have 20 days from the time the you received the judgement in order to file your exemption.

Be sure to have the form notarized and send a copy to the Plaintiffs.

Claim of Exemption and Request for Hearing

The following is a sample of the body of a Claim of Exemption & Request for Hearing form.

This is a sample form, so you can and should edit it to fit your needs. Make sure the style matches your case exactly.

The style is the top of the form that includes the court, the county, the case number and court division, as well as the Plaintiffs and Defendants name.

----Sample Form----

(Attach Case Style)


CLAIM OF EXEMPTION AND REQUEST FOR HEARING

I claim exemptions from garnishment under the following categories as checked:

_____ 1. Head of family wages. (You must check a. or b. below.)

_____ a. I provide more than one-half of the support for a child or other dependent and have net earnings of $500 or less per week.

_____ b. I provide more than one-half of the support for a child or other dependent, have net earnings of more than $500 per week, but have not agreed in writing to have my wages garnished.

_____ 2. Social Security benefits.

_____ 3. Supplemental Security Income benefits.

_____ 4. Public assistance (welfare).

_____ 5. Workers' Compensation.

_____ 6. Unemployment Compensation.

_____ 7. Veterans' benefits.

_____ 8. Retirement or profit-sharing benefits or pension money.

_____ 9. Life insurance benefits or cash surrender value of a life insurance policy or proceeds of annuity contract.

_____ 10. Disability income benefits.

_____ 11. Prepaid College Trust Fund or Medical Savings Account.

_____ 12. Other exemptions as provided by law. (Explain) ______________
                     _____________________________________________________
                     _____________________________________________________.

I request a hearing to decide the validity of my claim. Notice of the hearing should be given to me at:

Name: ___________________________
Address: _________________________
                   _________________________
Telephone: _______________________
E-mail: ___________________________

The statements made in this request are true to the best of my knowledge and belief.


I certify that a copy of this document was [√ / one only] (    ) mailed (    ) faxed and mailed (    ) hand-delivered to the person(s) listed below on
{date}_________________.

Other party or his/her attorney:
Name: ____________________                           
Address: __________________
__________________________                       
Fax Number: _______________                     


_________________________________
Defendant's signature
Date: ____________________________


STATE OF FLORIDA COUNTY OF _________________

Sworn and subscribed to before me this __________ day of (month and year) , by (name of person making statement)

Notary Public/Deputy Clerk

Personally Known _____ OR
Produced Identification _____
Type of Identification Produced __________________


----End Sample Claim of Exemption Form----

You can copy and paste the above sample into your favorite word processor and edit it to suit your needs.

Alternatively, you can purchase our fillable PDF Claim of Exemption form for immediate download ($2.95).

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