Fill and Sign the Washington Exemption Form

COURT OF WASHINGTON COUNTY OF Plaintiff, vs. Defendant(s), Garnishee. NO. Exemption Claim (Writ to garnish funds or property held by a financial institution) (EXMPCL) INSTRUCTIONS: 1. Read this whole form after reading the enclosed notice. Then put an X in the box or boxes that describe your exemption claim or claims and write in the necessary information on the blank lines. If additional space is needed, use the bottom of the last page or attach another sheet. 2. Make two copies of the completed form. Deliver the original form by first class mail or in person to the clerk of the court, whose address is shown at the bottom of the Writ of Garnishment. Deliver one of the copies by first class mail or in person to the plaintiff or plaintiff’s attorney, whose name and address are shown at the bottom of the writ. Keep the other copy. YOU SHOULD DO THIS AS QUICKLY AS POSSIBLE, BUT NO LATER THAN 28 DAYS (4 weeks) AFTER THE DATE ON THE WRIT. I/We claim the following money or property as exempt: IF BANK ACCOUNT IS GARNISHED: The account contains payments from: TANF, SSI, or other public assistance. I receive $ _____________ monthly. Social Security. I receive $ __________________ monthly. Veteran’s Benefits. I receive $ ______________ monthly. EXEMPTION CLAIM (EXMPCL ) - WPF GARN 01.0500 (06/2012) - RCW 6.27.140 Unemployment Compensation. I receive $ __________________ monthly. Child support. I receive $ _______________________ monthly. Pensions and retirement accounts including, but not limited to, U. S. Government Pension, federally qualified pension, individual retirement account (IRA) 401K, 403(b) and any state retirement system listed in RCW 41.50.030. I receive $ _________________ monthly. Other: Explain $200 exemption if debt is to state agency. $500 exemption for all other debts. IF EXEMPTION IN BANK ACCOUNT IS CLAIMED, ANSWER ONE OR BOTH OF THE FOLLOWING: No money other than from above payments are in the account. Moneys in addition to the above payments have been deposited in the account. Explain: . OTHER PROPERTY: Describe property: (If you claim other personal property as exempt, you must attach a list of all other personal property that you own.) Print: Your name If married or in a state registered domestic partnership, name of husband/wife/state registered domestic partner Your signature Signature of husband, wife, or state registered domestic partner EXEMPTION CLAIM (EXMPCL ) - WPF GARN 01.0500 (06/2012) - RCW 6.27.140 Address Address (if different from yours) Telephone number Telephone number (if different from yours) CAUTION: If the plaintiff objects to your claim, you will have to go to court and give proof of your claim. For example, if you claim that a bank account is exempt, you may have to show the judge your bank statements and papers that show the source of the money you deposited in the bank. Your claim may be granted more quickly if you attach copies of such proof to your claim. IF THE JUDGE DENIES YOUR EXEMPTION CLAIM, YOU WILL HAVE TO PAY THE PLAINTIFF’S COSTS. IF THE JUDGE DECIDES THAT YOU DID NOT MAKE THE CLAIM IN GOOD FAITH, HE OR SHE MAY DECIDE THAT YOU MUST PAY THE PLAINTIFF’S ATTORNEY FEES. EXEMPTION CLAIM (EXMPCL ) - WPF GARN 01.0500 (06/2012) - RCW 6.27.140