CLAIM OF EXEMPTION FOR WAGE GARNISHMENT

SUPERIOR COURT OF CALIFORNIA COUNTY OF ORANGE

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CLAIM OF EXEMPTION FOR WAGE GARNISHMENT

SELF-HELP FORM PACKET

SHC-CPJ-02 (Rev. 09/01/2021)

Self-Help Services can review your completed forms before you file them with the Court. To request review of your completed forms:

1. Complete the attached forms in black ink. 2. Scan your completed forms and save as a single PDF file. 3. Go to self-help (click the blue button labeled

Click Here to Contact Self-Help Services), attach the PDF, and complete the online request form. Make sure to select CIVIL as the case type on the form.

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RETURN TO LEVYING OFFICER. DO NOT FILE WITH COURT

WG-006

ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address):

FOR LEVYING OFFICER USE ONLY

(Levying Officer Name and Address)

TELEPHONE NO.:

FAX NO. (Optional):

E-MAIL ADDRESS (Optional):

ATTORNEY FOR (Name):

SUPERIOR COURT OF CALIFORNIA, COUNTY OF

STREET ADDRESS:

MAILING ADDRESS:

CITY AND ZIP CODE:

BRANCH NAME:

PLAINTIFF/PETITIONER:

LEVYING OFFICER FILE NUMBER:

DEFENDANT/RESPONDENT:

CLAIM OF EXEMPTION

(Wage Garnishment)

FOR COURT USE ONLY

READ EMPLOYEE INSTRUCTIONS (FORM WG-003) BEFORE COMPLETING THIS FORM

Copy all the information required above (except the top left space) from the Earnings Withholding Order. The top left space is for your name or your attorney's name and address. The original and one copy of this form with the Financial Statement attached must be filed with the levying officer.

DO NOT FILE WITH THE COURT.

1. My name is :

CASE NUMBER:

2. I need the following earnings to support myself or my family (check a or b):

a.

All earnings.

b.

$

each pay period.

3. Please send all papers to

me. my attorney

at the address

shown above

following (specify):

4. I am willing for the following amount to be withheld from my earnings each pay period during the withholding period. I understand that the judgment creditor can accept this offer by not opposing the Claim of Exemption, which will result in the following sum being withheld each pay period (check a or b):

a.

None

b.

Withhold $

each pay period.

5. I am paid daily

every two weeks

monthly

weekly

twice a month

other (specify):

NOTE: You must attach a properly completed Financial Statement form to this Claim of Exemption. The Financial Statement form is available without charge from the levying officer.

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Date:

(TYPE OR PRINT NAME)

Form Approved by the Judicial Council of California WG-006 [Rev. January 1, 2009]

CLAIM OF EXEMPTION (Wage Garnishment)

(SIGNATURE OF DECLARANT)

Page 1 of 1

Code of Civil Procedure, ? 706.124 courtinfo.

SHORT TITLE:

LEVYING OFFICER FILE NO.

WG-007/EJ-165

COURT CASE NO.

FINANCIAL STATEMENT

(Wage Garnishment--Enforcement of Judgment

NOTE: If you are married, this form must be signed by your spouse unless you and your spouse are living separate and apart. If this form is not signed by your spouse, check the applicable box on the reverse in item 9.

1. The following persons other than myself depend, in whole or in part, on me or my spouse for support:

MONTHLY TAKE-HOME

NAME

AGE

RELATIONSHIP TO ME

INCOME & SOURCE

a.

Spouse

b.

c.

d.

e.

2. My monthly income

a. My gross monthly pay is:.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2a. $

b. My payroll deductions are (specify purpose and amount):

(1 ) Federal and state withholding, FICA, and SDI. . . . . . . . . $

(2)

$

(3)

$

(4)

$

My TOTAL payroll deduction amount is (add (1) through (4)): ................................................ b. $

c. My monthly take-home pay is (a minus b): .................................................................................. c. $

d. Other money I get each month from (specify source):

is ......................... d. $

e. TOTAL MONTHLY INCOME (c plus d) .................................................................................. e. $

3. I, my spouse, and my other dependents own the following property:

a. Cash ..........................................................................................................................................

b. Checking, savings, and credit union accounts (list banks):

(1)

$

3a. $

(2)

$

(3)

$

b. $

c. Cars, other vehicles, and boat equity (list make, year of each):

(1)

$

(2)

$

(3)

$

c. $

d. Real estate equity ...................................................................................................................... d. $

e. Other personal property (jewelry, furniture, furs, stocks, bonds, etc.) (list separately):

Form Adopted by the Judicial Council of California

WG-007/EJ-165 [Rev. January 1, 2007]

FINANCIAL STATEMENT (Wage Garnishment--Enforcement of Judgment)

e. $

Page 1 of 2 Code of Civil Procedure, ?? 706.124, 703.530

courtinfo.

SHORT TITLE:

LEVYING OFFICER FILE NO.

WG-007/EJ-165

COURT CASE NO.

4. The monthly expenses for me, my spouse, and my other dependents a. Rent or house payment and maintenance ................................................................................. 4 a. $ b. Food and household supplies .................................................................................................... b. $ c. Utilities and telephone ............................................................................................................... c. $ d. Clothing ...................................................................................................................................... d. $ e. Medical and dental payments ..................................................................................................... e. $ f. Insurance (life, health, accident, etc.) ........................................................................................ f. $ g. School, child care ....................................................................................................................... g. $

h. Child, spousal support (prior marriage) ...................................................................................... h. $ I. Transportation & auto expenses (insurance, gas, repair) (list car payments in item 5) .............. i. $ j. Installment payments (insert total and itemize below in item 5) .................................................. j. $ k. Laundry and cleaning ................................................................................................................. k. $ l. Entertainment ............................................................................................................................. l. $ m. Other (specify):

m. $ n. TOTAL MONTHLY EXPENSES (add a through m): .................................................................... n. $

5. I, my spouse, and my other dependents owe the following debts:

CREDITOR'S NAME

FOR

MO. PAYMENTS BALANCE OWED

OWED BY (State person's name)

6. Other facts which support this Claim of Exemption (i.e., unusual medical needs, school tuition, expenses for recent family emergencies, or other unusual expenses to help your creditor and the judge understand your budget) (describe): (If more space is needed, attach page labeled Attachment 6.)

7.

An earnings withholding order is now in effect with respect to my earnings or those of my spouse or dependents named in

item 1 (specify each person's name and monthly amount):

8.

A wage assignment for support is now in effect with respect to my earnings or those of my spouse or dependents named in

item 1 (specify each person's name and monthly amount):

9.

My spouse has signed below.

I have no spouse. My spouse and I are living separate and apart.

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Date:

(TYPE OR PRINT NAME)

(SIGNATURE)

(TYPE OR PRINT NAME OF SPOUSE)

WG-007/EJ-165 [Rev. January 1, 2007]

FINANCIAL STATEMENT (Wage Garnishment--Enforcement of Judgment)

(SIGNATURE OF SPOUSE)

Page 2 of 2

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