Wage Garnishment Exemption Claim Form

Wage Garnishment Exemption Claim Form
Use this form to request an exemption from wage garnishment and provide the information and documents needed to review your claim.
Claimant Information
Full Name
First NameMiddle NameLast Name
Mailing Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred Contact Method
Case/Reference Number
Employer and Garnishment Details
Employer Name
Employer Payroll Contact
First NameLast Name
Garnishment Start Date
MonthDayYear
Date
Court or Agency Name
Case or Reference Number
Amount Garnished Per Pay Period or Description
Exemption Claim Basis
Primary exemption basis
Other hardship basis
Explain your exemption basis
If other, specify the basis
Financial and Household Information
Monthly take-home income
Other household income
Number of dependents
Essential monthly expenses
Rent or mortgage amount
Utilities cost
Childcare costs
Medical expenses
Supporting Documents and Declaration
Recent Pay Stubs
Cancelof
Proof of Income / Benefits
Cancelof
Proof of Household Expenses
Cancelof
Declaration
Signature
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Date Signed
MonthDayYear
Date
Should be Empty: