Fill and Sign the Minnesota Exemption Form

STATE OF MINNESOTA DISTRICT COURT COUNTY OF JUDICIAL DISTRICT FAMILY COURT DIVISION In Re the Marriage of: Court File No. , Petitioner, EXECUTION EXEMPTION NOTICE AND NOTICE OF AND INTENT TO LEVY EARNINGS WITH IN TEN DAYS , Respondent, THE STATE OF MINNESOTA TO THE ABOVE-NAMED JUDGMENT DEBTOR: PLEASE TAKE NOTICE that a levy may be served upon your employer or other third parties, without any further court proceedings or notice to you, ten days or more from the date hereof. Your earnings are completely exempt from execution levy if you are now a recipient of relief based on need, if you have been a recipient of such relief within the last six months, or if you have been an inmate of a correctional institution in the last six months. Relief based on need includes, only Aid to Families with Dependant Children (AFDC), AFDC- Emergency Assistance (AFDC-EA), Medical Assistance (MA), General Assistance (GA), General Assistance Medical Care (GAMC), Emergency General Assistance (EGA), Work Readiness, Minnesota Supplemental Aid (MSA), MSA Emergency Assistance (MSA-EA), Supplemental Security Income (SSI), and Energy Assistance. If you wish to claim an exemption, you should fill out the appropriate form below, sign it, and send it to the creditor's attorney and the garnishee. You may wish to contact the attorney for the judgment creditor in order to arrange for a settlement of the debt or contact an attorney to advise you about exemptions or other rights. - 1 - PENALTIES 1. Be advised that even if you claim an exemption, an execution levy may still be served on your employer. If your earnings are levied on after you claim an exemption, you may petition the court for a determination of your exemption. If the court finds that the judgment creditor disregarded your claim of exemption in bad faith, you will be entitled to costs, reasonable attorney fees, actual damages, and an amount not to exceed $100. 2. HOWEVER, BE WARNED if you claim an exemption, the judgment creditor can also petition the court for a determination of your exemption, and if the court finds that you claimed an exemption in bad faith, you will be assessed costs and reasonable attorney's fees plus an amount not to exceed $100. 3. If after receipt of this notice, you in bad faith take action to frustrate the garnishment, thus requiring the judgment creditor to petition the court to resolve the problem, you will be liable to the judgment creditor for costs and reasonable attorney fees plus an amount not to exceed $100. Dated: _____________ _______________________________ __________________ Attorney for Petitioner #1 Address #2 Address City, State Zip Telephone ( ____ ) __________ Attorney Reg. No.: ______ - 2 - JUDGMENT DEBTOR'S EXEMPTION CLAIM NOTICE I hereby claim that my earnings are exempt from execution because: 1. I am presently a recipient of relief based on need. (Specify the program, case number, and the county from which relief is being received.) ______________ ______________ ______________ Program Case Number (if known) County 2. I am not now receiving relief based on need, but I have received relief based on need within the last six months. (Specify the program, case number, and the county from which relief has been received.) ______________ ______________ ______________ Program Case Number (if known) County 3. I have been an inmate of a correctional institution within the last six months. (Specify the correctional institution and location). ______________ ______________ ______________ ______________ Correctional Institution Location 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 or the 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 institution within the last six months. I have mailed or delivered a copy of this form to the creditor or the creditor's attorney. DATED ______________ ___________________________ Judgment Debtor ______________ ______________ ______________ ______________ ______________ ______________ - 3 -