Free Civil Court Form 10 - Minnesota

File Size: 54.8 kB
Pages: 3
File Format: PDF
State: Minnesota
Category: Court Forms - State
Author: ReilC
Word Count: 1,050 Words, 6,176 Characters
Page Size: Letter (8 1/2" x 11")

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State of Minnesota
Select County

District Court
Judicial District: Court File Number: Case Type: Civil

Plaintiff (Creditor/Debtor),


Exemption Notice (Minn. Stat. 550.143, subd. 3; 571.912)

Defendant (Creditor/Debtor).

To: An

(Debtor) has been served on
(Order for Attachment, Garnishment Summons, or Levy of Execution) (Bank or other Financial Institution)

where you have an account. Your account balance is $ The amount being held is $ . .

However, all or a portion of the funds in your account will normally be exempt from creditors' claims if they are in one of the following categories: 1. relief based on need. This includes: Minnesota Family Investment Program (MFIP), Emergency Assistance (EA), Work First Program, Medical Assistance (MA), General Assistance (GA), General Assistance Medical Care (GAMC), Emergency General Assistance (EGA), Minnesota Supplemental Aid (MSA) MSA Emergency Assistance (MSA-EA), Supplemental Security Income (SSI), and Energy Assistance; 2. Social Security benefits (Old Age, Survivors, or Disability Insurance); 3. reemployment benefits, workers' compensation, or veterans' benefits; 4. an accident, disability, or retirement pension or annuity; 5. life insurance proceeds; 6. the earnings of your minor child and any child support paid to you; or 7. money from a claim for damage or destruction of exempt property (such as household goods, farm tools, business equipment, a mobile home, or a car). The following funds are also exempt: 8. all earnings of a person in category 1; 9. all earnings of a person who has received relief based on need, or who has been an inmate of a correctional institution, within the last six months; 10. 75 percent of every debtor's after tax earnings; and 11. all of a debtor's after tax earnings below 40 times the federal minimum wage

Time Limit on Exemptions After Deposit in Bank.
Categories 10 and 11: 20 days Categories 8 and 9: 60 days All Other Categories: no time limit, as long as funds are traceable to the exempt source. (In tracing
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funds, the first-in, first-out method is used. This means money deposited first is spent first.) The money being sought by the creditor is being held in your account to give you a chance to claim an exemption.

To Claim an Exemption.
Fill out, sign, and mail or deliver one copy of the attached exemption claim form to the institution which sent you this notice and mail or deliver one copy to the creditor's attorney. In the event that there is no attorney for the creditor, then such notice shall be sent directly to the creditor. The address for the creditor's attorney or the creditor is set forth below. Both copies must be mailed or delivered on the same day. Note: You may help resolve your claim faster if you send to the creditor's attorney written proof or documents that show why your money is exempt. If you have questions regarding the documents to send as proof of an exemption, call the creditor's attorney. If you do not send written proof and the creditor's attorney has questions about your exemption claim, the creditor's attorney may object to your claim which may result in a further delay in releasing your exempt funds. If the financial institution does not get the exemption claim back from you within 14 days of the date they mailed or gave it to you, they will be free to turn the money over to the sheriff or the creditor. If you are going to claim an exemption, do so as soon as possible, because your money may be held until it is decided.

If you Claim an Exemption.
1. nonexempt money can be turned over to the creditor or sheriff; 2. the financial institution will keep holding the money claimed to be exempt; and 3. the financial institution will release the money to you seven days after receiving your exemption claim, unless it receives an objection to your exemption claim.

If the Creditor Objects to your Exemption Claim.
The institution will hold the money until a court decides if your exemption claim is valid, BUT ONLY IF the institution gets a copy of your court motion papers asserting the exemption WITHIN TEN DAYS after the objection is personally served on you, or within thirteen days from the date the objection is mailed to you. You may wish to consult an attorney at once if the creditor objects to your exemption claim.

Motion to Determine Exemption.
At any time after your funds have been held, you may ask for a court decision on the validity of your exemption claim by filing a Request for Hearing. This form may be obtained at the office of the court administrator of the above court.

If you claim an exemption in bad faith, or if the creditor wrongly objects to an exemption in bad faith, the court may order the person who acted in bad faith to pay costs, actual damages, attorney fees, and an additional amount of up to $100.00.




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Name of Creditor's Attorney or Creditor's Name Address

Exemption (If you claim an exemption complete the following): a. Amount of exemption claim. I claim ALL the funds being held are exempt. I claim SOME of the funds being held are exempt. The exempt amount is $ . b. Basis for exemption. Of the eleven categories listed above, I am in category number (If more than one category applies, you may fill in as many as apply.) The source of the exempt funds is the following:

(If the source is a type of relief based on need, list the case number and county: Case Number: County:


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 creditor or its attorney only whether or not I am or have been a recipient of relief based on need or an inmate of a correctional institute within the last six months. I have mailed or delivered a copy of the exemption notice to the creditor or creditor's attorney if represented at the address indicated above. Dated:

Name: Street Address: City/State/Zip: Telephone:




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