Fill and Sign the Motion to Claim Form

File No. Judgment Abstract No. Date Judgment Filed Name Of Judgment Creditor (Plaintiff) MOTION TO CLAIM EXEMPT PROPERTY (STATUTORY EXEMPTIONS) (Use If Judgment Filed On Or After Jan. 1, 2006) G.S. 1C-1603(c) Name Of Judgment Debtor (Defendant) VERSUS In The General Court Of Justice District Superior Court Division STATE OF NORTH CAROLINA County (Over) NOTE TO JUDGMENT DEBTOR: The Clerk of Superior Court cannot fill out this form for you. If you need assistance, you should talk with an attorney. JUDGMENT DEBTOR NOTICE OF RIGHTS: (a) You have the right to retain an interest in certain property free from collection efforts by the judgment creditor. (b) To preserve that right, you are required to respond to the notice by filing a motion or petition to claim exempt property, including a schedule of assets that are claimed as exempt, no later than 20 days after you receive the notice, and you must also mail or take a copy to the judgment creditor at the address provided in the notice. (c) You have the option to request a hearing to claim exemptions rather than filing a schedule of assets. (d) You may have exemptions under State and federal law that are in addition to those listed on the form for the debtor’s statement that is included with the notice, such as Social Security benefits, unemployment benefits, workers’ compensation benefits, and earnings for your personal services rendered within the last 60 days. (e) There is a procedure for challenging an attachment or levy on your property . (f) You may wish to consider hiring an attorney. (g) Failure to respond within the required time results in the loss of statutory rights. I, the undersigned, move to set aside the property claimed below as exem\ pt. 1. I am a citizen and resident of . 2. a. I am married to . b. I am not married. 3. My current address is . 4. The following persons are dependent on me for support: Street Address Of Residence 5. I wish to claim as exempt (keep from being taken) my interest in the following real or personal property, or in a coopera\ tive that owns property, that I use as a residence. I also wish to claim my interest in\ the following burial plots for myself or my dependents. I understand that my total interest claimed in the residence and burial pl\ ots may not exceed $35,000.00, except that if I am unmarried and am 65 years of age or older, I am entitled to claim a total exemptio\ n in the residence and burial plots not to exceed $60,000.00, so long as the property was previously owned by me as a tenant by the en\ tireties or as a joint tenant with rights of survivorship, and the former co-owner of the property is deceased. County Where Property Located TownshipNo. By Which Tax Assessor Identifies Property Name(s) Of Person(s) Dependent On Me AgeRelationship Legal Description (Attach a copy of your deed or other instrument of conveyance or describe property in as much detail as possible. Attach additional sheets if necessary.) I am unmarried and 65 years of age or older and this property was previo\ usly owned by me as a tenant by entireties or as a joint tenant with rights of survivorship and the former co-owner of the proper\ ty is deceased. Name(s) Of Owner(s) Of Record Of Residence Estimated Value Of Residence (What You Think You Could Sell It For) $ AOC-CV-415, Rev. 8/17