Fill and Sign the Exemption Garnishment Form

STATE OF MINNESOTA __________ DISTRICT COURT COUNTY OF __________________ __________ JUDICIAL DISTRICT FAMILY COURT DIVISION Court File No. __________ __________________ , JUDGMENT CREDITOR, EXEMPTION NOTICE AND __________________ , JUDGMENT DEBTOR, An order for attachment, garnishment summons, or levy of execution has been served on _________ (Bank or other Financial Institution) _________ where you have an account. Your account balance is $ _________ The amount being held is $ _________ However, all or a portion of the funds in your account will normally be exempt from creditors' claims if they are in one of the following categories: (1) Relief based on need . This includes Aid to Families with Dependent Children (AFDC), AFDC-Emergency Assistance (AFDC-EA), Medical Assistance (MA), General Assistance (GA), General Assistance Medical Care (GAMC), Emergency General Assistance (EMA), Work Readiness, Minnesota Supplemental Aid (MSA), MSA Emergency Assistance (MSA-EA), Supplemental Security Income (SSI), and Energy Assistance; (2) Social Security benefits (Old Age, Survivors, or Disability Insurance); (3) unemployment compensation, workers' compensation, or veteran's benefits; (4) an accident, disability, or retirement pension or annuity; (5) life insurance proceeds; (6) the earnings of your minor child; or (7) money from a claim for damage or destruction of exempt property (such as household goods, farm tools, business equipment, a mobile home, or a car). The following funds are also exempt: (8) all earnings of a person in category (1); (9) all earnings of a person who has received relief based on need, or who has been an inmate of a correctional institution, within the last six months. (10) Seventy-five percent (75%) of every debtor's after tax earnings; or (11) all of a judgment debtor's after tax earnings below 40 times the federal minimum wage. TIME LIMIT ON EXEMPTIONS AFTER DEPOSIT IN BANK: Categories (10) and (11): 20 days. Categories (8) and (9): 60 days. All others: no time limit, as long as funds are traceable to the exempt source. (In tracing funds, the first-in, first-out method is used. This means money deposited first is spent first.) The money being sought by the creditor is being held in your account to give you a chance to claim an exemption. TO CLAIM AN EXEMPTION: Fill out, sign, and mail or deliver one copy of this exemption claim form to the institution, which sent you this notice and mail or deliver one copy to the judgment creditor's attorney. The address for the judgment creditor's attorney is set forth below. Both copies must be mailed or delivered on the same day. If they do not get the exemption claim back from you within fourteen (14) days of the date they mailed or gave it to you, they will be free to turn the money over to the attorney for the judgment creditor. If you are going to claim an exemption, do so as soon as possible, because your money may be held until it is decided. IF YOU CLAIM AN EXEMPTION: - 2 - (1) nonexempt money can be turned over to the judgment creditor or sheriff; (2) the financial institution will keep holding the money claimed to be exempt; and (3) seven days after receiving your exemption claim, the financial institution will release the money to you unless before then it receives an objection to your exemption claim. IF THE JUDGMENT CREDITOR OBJECTS TO YOUR EXEMPTION CLAIM: The institution will hold the money until a court decides if your exemption claim is valid, BUT ONLY IF the institution gets a copy of your court motion papers asserting the exemption WITHIN 10 DAYS after the objection is mailed or given to you. You may wish to consult an attorney at once if the judgment creditor objects to your exemption claim. MOTION TO DETERMINE EXEMPTION: At any time after your funds have been held, you may ask for a court decision on the validity of your exemption claim by filing a request for hearing, which may be obtained at the office of the clerk of the above court. PENALTIES: If you claim an exemption in bad faith, or if the judgment creditor wrongly objects to an exemption in bad faith, the court may order the person who acted in bad faith to pay costs, actual damages, attorney fees, and an additional amount of up to $100. Dated: Name: ____________________ Title: Attorney for Judgment Creditor Address: ____________________ Address: ____________________ City, State, Zip: ____________________ Phone: _______________ Fax: _______________ E-Mail: ____________________ Attorney Reg. No.: ____________________ - 3 - EXEMPTION: (a) Amount of exemption claim. I claim ALL the funds being held are exempt. I claim SOME of the funds being held are exempt. The exempt amount is $ ___________________ . (b) Basis for exemption. Of the eleven (11) categories listed above, I am in category number ____ (If more than one category applies, you may fill in as many as apply.) The source of the exempt funds is the following: ______________________________________________________________ (If the source is a type of relief based on need, list the case number and county: case number: _______________ ; _____________________ County: _______________ ) I hereby authorize any agency that has distributed relief to me or any correctional institution in which I was an inmate to disclose to the above named judgment creditor's attorney only whether or not I am or have been a recipient of relief based on need or an inmate of a correctional institute within the last six (6) months. I have mailed or delivered a copy of the exemption notice to the judgment creditor's attorney. Dated: BY THE COURT: Judge of District Court ______ Judicial District - 4 -