Free AFFIDAVIT FOR EXEMPTIONS (SCA-M665) - West Virginia

IN THE MAGISTRATE COURT OF
Plaintiff

COUNTY, WEST VIRGINIA
Case No.

Address v. Defendant

Address

AFFIDAVIT FOR EXEMPTIONS
(Applicable to writs of execution, suggestions and suggestee executions) The judgment debtor, correct: , being duly sworn, states that the following is true and

1. I understand that I cannot claim exemption of personal property if the judgment in this case arose from the purchase or lease of that specific personal property. I also understand that I cannot claim exemption from execution more than $15,000 in the aggregate in personal property listed on this form. 2. I claim exemption of personal property as one of the following: (check only one box) I am an individual residing in West Virginia OR I am the dependent of an individual residing in West Virginia

3. I claim exemption of personal property based on the fact that: (Check all that apply. If no box applies, then the personal property exemption is not available and this form should not be completed.) A. The total estimated value of my motor vehicle, minus liens, is $ , and I, therefore, claim $ of it as

exempt from execution. (Exemption may not exceed $5,000) [W.Va. Code §38-8-1(a)(1)] B. The total estimated value of my personal property, (household goods, furniture, toys, animals, appliances, books and wearing apparel) minus liens, is $ , and I, therefore, claim $ of it as exempt from execution.

Exemption may not exceed $8,000) [W.Va. Code §38-8-1(a)(2)] C. The total estimated value of my personal property (implements, professional books or tools of my trade), minus liens, is $ , and I, therefore, claim $ of it as exempt from execution. (Exemption may not exceed $3,000)

[W.Va. Code §38-8-1(a)(3)] D. The total estimated value of my funds on deposit in a federally insured financial institution, wages or salary, does not exceed the greater of 1) $1,000 OR 2) 125% of the amount of annualized federal poverty level of my household divided by the number of pay periods for the year, and I therefore claim $ Code §38-8-1(a)(4)] Total claimed exemption of items listed in 3.A., B., C., and/or D. above is $ 4. . of it as exempt from execution. [W.Va.

I claim as exempt from execution my funds on deposit in an individual retirement account (IRA), including a simplified employee pension (SEP), in my name and I state that it is not or has not been subject to an excise or other tax on excess contributions under Section 4973 or Section 4979 of the Internal Revenue Code of 1986, or both sections, or any successor provisions, regardless of whether the tax is or has been paid. [W.Va. Code §38-8-1(a)(5)]

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The total estimated value of my property, minus liens, exceeds $15,000, and I claim the following items as exempt from execution (list the numbers of each line in the tables on pages 2 and 3 and on any attached sheets which you claim as exempt): Vehicles: Household Property: Implements, Professional Books or Tools of my trade: Funds on deposit, wages or salary: The debt in this case arose from a consumer credit transaction (goods purchased or leased on credit for personal, family, household or agricultural purpose, and payable in installments or subject to a sales finance charge), and I therefore claim as exempt (list the numbers of each line on the back page and any attached sheets which you claim as exempt): [W.Va. Code § 46A-2-136] Clothing, up to $200 All family health equipment Life insurance policy, except cash value of accrued dividends All children's property Tools of trade and income-producing property, up to $1,000 Household furniture, appliances, furnishings and fixtures, up to $1,000

The following is a list of all my personal vehicles in my possession or in the possession of another and liens, if any. Vehicle (including make, model and year) Location Estimated Fair Market Value Value of Lien (if any) Lien Holder (if any) Estimated Fair Market Value (Minus Liens)

1 2 3 4

$

Total Check here if additional pages are attached because more space is needed to complete the list of vehicles. The following is a list of all of my household property in my possession or in the possession of another and liens, if any. Personal Property (household goods, furniture, toys, animals, appliances, books and wearing apparel) Location Estimated Fair Market Value Value of Lien (if any) Lien Holder (if any) Estimated Fair Market Value (Minus Liens)

1 2 3 4

$

Total Check here if additional pages are attached because more space is needed to complete the list of household property.

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The following is a list of all of my implements, professional books or tools of my trade in my possession or in the possession of another and liens, if any. Personal Property (implements, professional books or tools of my trade) Where applicable, list brand name and year purchased 1 2 3 4 Total Check here if additional pages are attached because more space is needed to complete the list of implements, professional books or tools of the trade. The following is a list of all of my funds on deposit, wages or salary. Funds on deposit in a federally Financial Institution insured financial institution, wages or salary 1 2 3 4 Total Check here if additional pages are attached because more space is needed to complete the list of funds on deposit, wages or salary. The following is a list of all of my funds on deposit in an IRA. Funds on deposit in an individual retirement account (IRA) 1 2 3 4 Total Check here if additional pages are attached because more space is needed to complete the list of funds on deposit in an IRA. Name of Investment Account Amount Amount Location Estimated Fair Market Value Value of Lien (if any) Lien Holder (if any) Estimated Fair Market Value (Minus Liens)

$

$

$

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Signature of Judgment Debtor Taken, subscribed and sworn or affirmed before me this My commission expires on: Signature of Notary/Magistrate Court Clerk NOTICES TO JUDGMENT DEBTOR: · If a Writ of Execution has been issued against your personal property and you wish to claim exemptions, you should complete this form and deliver the original and one copy to the sheriff. If a Suggestee Execution has been issued against your wages and you wish to claim exemptions, you should complete this form each pay period, deliver the original and one copy to the clerk of the court and request that the clerk issue a temporary release of your wages. If a Suggestion of Personal Property other than wages has been issued against your property and you wish to claim exemptions, you should complete this form and deliver the original and one copy to the clerk of the court and request a certificate of exemption to release the suggested property. · If the creditor disagrees with the statements in this affidavit, the creditor may request and appraisement of the suggested property. The intentional filing of a false affidavit may constitute a criminal violation. day of

·

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