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XEMPTION CLAIM FORM NAME AND ADDRESS OF JUDGMENT NAME AND ADDRESS OF FINANCIAL CREDITOR OR ATTORNEY INSTITUTION (To be completed by judgment (To be completed by judgment creditor or attorney) creditor or attorney) ADDRESS ADDRESS A ----------------------B ------------------------------------------------------------------Directions: To claim that some or all of the funds in your account are exempt, complete both copies of this form, and make one copy for yourself. Mail or deliver one form to ADD.

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