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Claim of Exemption From Execution Fillable PDF
Claim of Exemption From Execution Fillable PDF
2 (Name)
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(Address)
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(City, State, Zip Code)
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(Telephone Number)
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(E-mail Address)
7 Defendant/ Other, In Proper Person
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EIGHTH JUDICIAL DISTRICT COURT
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CLARK COUNTY, NEVADA
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11 , Case No.:
Plaintiff(s), Dept. No.:
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13 vs.
CLAIM OF EXEMPTION FROM
14 , EXECUTION
Defendant(s).
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19 I am a Defendant in this case and have had my wages withheld or have received a Notice of
21 property.
22 I am not a Defendant in this case, but my wages, money, benefits, or property are the subject
24 My wages, money, benefits, or property are exempt by law from execution as indicated below.
25 Pursuant to NRS 21.112(4), if the Plaintiff/Judgment Creditor does not file an objection and notice of
26 hearing in response to this Claim of Exemption within eight judicial days after my Claim of Exemption
27 from Execution has been served, any person who has control or possession over my wages, money,
28 benefits, or property (such as my employer or bank, for example) must release them to me within nine
2 (Check all of the following boxes that apply to your wages, money, benefits, or property.)
3 Money or payments received pursuant to the federal Social Security Act, including retirement,
4 disability, survivors' benefits, and SSI. (NRS 21.090(1)(y) and 42 U.S.C. § 407(a).)
5 Money or payments for assistance received through the Nevada Department of Health and
6 Human Services, Division of Welfare and Supportive Services, pursuant to NRS 422.291. (NRS
9 (NRS 21.090(1)(hh).)
10 Money or compensation payable or paid under NRS 616A to 616D (worker's compensation/
13 Money or payments received as retirement benefits under the federal Civil Service Retirement
16 earnings if my gross weekly salary is $770 or less. "Disposable earnings" are the earnings
17 remaining "after the deduction . . . of any amounts required by law to be withheld." (NRS
18 21.090(1)(g)(1).) The "amounts required by law to be withheld" are federal income tax,
20 Check here if your disposable weekly earnings to do not exceed $362.50 or 50 times the
21 federal minimum wage (50 x $7.25 = $362.50), in which case ALL of your disposable
23 Check here if your disposable weekly earnings are between $362.50 and $483.33, in which
24 case your exempt income is always $362.50. Your non-exempt income is your weekly
25 disposable earnings minus $362.50, which equals (insert amount here): $ per
27 Money or benefits received pursuant to a court order for the support, education, and maintenance
28 of a child, or for the support of a former spouse, including arrearages. (NRS 21.090(1)(s)-(t).)
3 $10,000 or less of my money or personal property, identified as (describe the specific money or property you
7 pursuant to applicable limitations and requirements of the Internal Revenue Code, including, but
8 not limited to, an IRA, 401k, 403b, or other qualified stock bonus, pension, or profit-sharing plan.
9 (NRS 21.090(1)(r).)
10 All money, benefits, privileges, or immunities derived from a life insurance policy. (NRS
11 21.090(1)(k).)
12 Money, benefits, or refunds payable or paid from Nevada's Public Employees' Retirement System
15 and land) or a mobile home where my equity does not exceed $550,000. (NRS 21.090(1)(l).)
16 My dwelling, occupied by me and my family, where the amount of my equity does not exceed
17 $550,000, and I do not own the land upon which the dwelling is situated. (NRS 21.090(1)(m).)
18 Check here if the judgment being collected arises from a medical bill. If it does, your
19 primary dwelling and the land upon which it is situated (if owned by you), including a mobile
20 or manufactured home, are exempt from execution regardless of your equity. (NRS 21.095.)
21 My vehicle, where the amount of equity does not exceed $15,000, or I will pay the judgment
23 Check here if your vehicle is specially equipped or modified to provide mobility for you or
24 your dependent and either you or your dependent has a permanent disability. Your vehicle is
27 (NRS 21.090(1)(q).)
4 (NRS 21.090(1)(b).)
5 Money or payments received from a private disability insurance plan. (NRS 21.090(1)(ee).)
6 Money in a trust fund for funeral or burial services pursuant to NRS 689.700. (NRS 21.090(1)(ff).)
7 My professional library, equipment, supplies, and the tools, inventory, instruments, and materials
8 used to carry on my trade or business for the support of me and my family not to exceed $10,000
10 Money that I reasonably deposited with my landlord to rent or lease a dwelling that is used as my
11 primary residence, unless the landlord is enforcing the terms of the rental agreement or lease.
12 (NRS 21.090(1)(n).)
13 Money or payments, up to $16,150, received as compensation for personal injury, not including
14 compensation for pain and suffering or actual pecuniary loss, by me or by a person upon whom I
16 Money or payments received as compensation for loss of my future earnings or for the wrongful
17 death or loss of future earnings of a person upon whom I was dependent, to the extent reasonably
20 Money paid or rights existing for vocational rehabilitation pursuant to NRS 615.270. (NRS
21 21.090(1)(jj).)
23 Other:
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26 (Some direct-deposit funds are automatically protected and should not be taken from your bank account. If automatically
27 protected money was taken from your bank account, check the appropriate box below and attach proof of direct-deposit benefits.)
28 All exempt federal benefits that were electronically deposited into my account during the prior
2 protected amount. (31 C.F.R. part 212.6(a).) Money in my personal bank account that exceeds
4 Exempt state or federal benefits were electronically deposited into my personal bank account
5 during the 45-day period preceding Plaintiff's service of the writ of execution or garnishment
relating to my personal bank account, and under Nevada law, I am entitled to full and customary
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access to $2,000 or the entire amount in the account, whichever is less, regardless of any other
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deposits of money into the account. Money in my personal bank account that exceeds that
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amount may be subject to the exemptions stated above. (NRS 21.105.)
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A writ of execution or garnishment was levied on my personal bank account, and under Nevada
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law, I am entitled to full and customary access to $400 or the entire amount in my account,
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whichever is less, unless the writ is for the recovery of money owed for the support of any person.
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Money in my personal bank account that exceeds $400 may be subject to the exemptions stated
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above. (NRS 21.105.)
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Pursuant to NRS 21.112(4), if you are a Garnishee or other person who has control or possession
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over my exempt wages, bank accounts, benefits, other accounts/funds, or personal or real
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property, as stated above, you must release that money or property to me within nine judicial days after
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my Claim of Exemption from Execution was served on you, unless the Plaintiff/Judgment Creditor files
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an objection and notice of hearing within eight judicial days after service of my Claim of Exemption from
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Execution, which the Plaintiff/Judgment Creditor will serve on you by mail or in person.
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DATED this ________ day of ______________________________, 20______.
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I declare under penalty of perjury under the laws of the
22 State of Nevada that the foregoing is true and correct.
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______________________________________ (signature)
24 ______________________________________ (print name)
Defendant/ Other, In Proper Person
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3 a true and correct copy of the foregoing CLAIM OF EXEMPTION FROM EXECUTION in the
4 United States Mail, with first-class postage prepaid, addressed to the following (insert the name and address of the
5 following parties/entities):
9 Sheriff or Constable:
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12 Garnishee: Employer
Bank
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Other
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18 ______________________________________ (signature)
______________________________________ (print name)
19 Defendant/ Other, In Proper Person
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