IN THE CIRCUIT/COUNTY COURT OF SIXTH JUDICIAL CIRCUIT
IN AND FOR PINELLAS COUNTY FLORIDA
UCN: ______________________________ Reference No.: ______________________________
__________________________________________
__________________________________________
Plaintiff(s),
vs.
__________________________________________
__________________________________________
Defendant(s).
and
__________________________________________
__________________________________________
Garnishee.
CLAIM OF EXEMPTION AND REQUEST
FOR HEARING
PURSUANT TO
F.S. 77.041
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 $750.00 or less per week.
______ (b). I provide more than one-half of the support for a child or other dependent, and have net earnings of more than $750.00 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. Worker’s 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 an 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:
Address: __________________________________________________________________________________________________
Telephone Number: _______________________________
I CERTIFY UNDER OATH AND PENALTY OF PERJURY that a copy of this CLAIM OF EXEMPTION AND REQUEST FOR
HEARING has been furnished by (check one) United States mail or hand delivery on
the _________ day of __________________________, 20______, to:______________________________________________________________
______________________________________________________________________________________________________________________.
(names and addresses of Plaintiff or Plaintiff’s attorney and of Garnishee or Garnishee’s attorney to whom this document was furnished)
I FURTHER CERTIFY UNDER OATH AND PENALTY OF PERJURY that the statements made in this request are true to the best of my knowledge
and belief.
_____________________________________________ _____________________________________________
Defendant’s signature Date
STATE OF FLORIDA
COUNTY OF PINELLAS
Sworn and subscribed to before me this ______ day of ___________________ , by ___________________________________________
Defendant Name
Signature of Notary Public - State of Florida _____________________________________________________________________
Print, Type or Stamp Commissioned Name of Notary Public _________________________________________________________
Type of identification produced _________________ Personally known _________________ or produced identification _________________
CTCIV228/COCIV77 (Rev. 2/16)
