Form 1 Notice of Lien

NOTICE OF LIEN

TO:

(Name/Address of recorder or asset holder)

Obligor:

(Name/Address/DOB/SSN)

FROM:

(IV-D Agency or name of obligee

and/or his or her private attorney or entity acting on behalf of the obligee,

address, phone, e-mail address, fax number)

Obligee:

(Name)

IV-D Case #:

(or non-IV-D docket #)

This lien results, by operation of law, from a child support order, entered on ___________

by ___________ in___________ tribunal number ___________.

As of _________, the obligor owes unpaid support in the amount of $ _______. This judgment may be subject to interest.

Prospective amounts of child support, not paid when due, are judgments that are added to the lien amount. This lien attaches to all non-exempt real and/or personal property of the above-named obligor which is located or existing within the State/county of filing, including any property specifically described below.

Specific description of property:

Page 1 of 3

All aspects of this lien, including its priority and enforcement, are governed by the law of the State where the property is located. An obligor must follow the laws and procedures of the State where the property is located or recorded. An obligor may also contact the entity sending the

lien. This lien remains in effect until released or withdrawn by the issuing agency, the obligee, the entity acting on behalf of the obligee, or in accordance with the laws of the State where the property is located.

Note to Lien Recorder: Please provide the sender with a copy of the filed lien, containing the recording information, at the address provided above.

Check either “A” or “B” below. The option that does not apply may be omitted from the form.

If “B” is checked, the form must be notarized.

1. [ ] Submitted by a IV-D agency/office on behalf of the named obligee

As an authorized agent of a State or Tribal, or subdivision of a State or Tribal, agency

responsible for implementing the child support enforcement program set forth in Title IV, Part D, of the Federal Social Security Act (42 U.S.C. 651 et seq.), I have authority to file this child support lien in any State, or U.S. Territory. For additional information regarding this lien, including the pay-off amount, please contact the authorized agency and reference its case number, both listed above.

__________ ___________________________

Date Authorized Agent

_____________________________

Print name, e-mail address, phone and fax number

B. [ ] Submitted by an obligee or a private (non-IV-D) attorney or entity on behalf of an obligee

I am [ ] the obligee of the above referenced order [or]

[ ] an attorney or entity representing the above named obligee

I certify under penalty of perjury that the information contained in this notice is true and accurate and that this lien is submitted in accordance with the laws of the State of _________________. For additional information regarding this lien, including the pay-off amount, please contact the obligee listed above.

____________ ______________________________

Date Signature

_______________________________

Print name, e-mail address, phone and fax number

Page 2 of 3

Notary State:________________________

County:_______________________

I certify that __________________________ appeared before me and is known to me as the individual who signed the above.

Date: _________ _______________________

Notary Public

My appointment expires __________________

Notice: Respondents are not required to respond to this information collection unless it displays a valid OMB

control number. The average burden for responding to this information collection is estimated at 30 minutes. If you believe this estimate is inaccurate, or if you have ideas to reduce this burden, please provide comment to the issuing agency.

OMB Control #: 0970-0153 Expiration Date: 02/28/2014 (Please note, this expiration date is for the OMB form and not the lien itself.)

Page 3 of 3

Notice of Lien

TO: (1)

(Name/Address of recorder or asset holder)

Obligor: (2)

(Name/Address/DOB/SSN)

FROM: (3)

(IV-D Agency or name of obligee

and/or his or her private attorney,

or entity acting on behalf of the obligee,

address, phone, e-mail address, fax number)

Obligee: (4)

(Name)

IV-D Case #: (5)

(or non-IV-D docket #)

This lien results, by operation of law, from a child support order, entered on _____(6)______

by _____(7)______ in_____(8)______ tribunal number ______(9)_____.

As of __(10)____, the obligor owes unpaid support in the amount of $ __(11)___. This judgment may be subject to interest.

Prospective amounts of child support, not paid when due, are judgments that are added to the lien amount. This lien attaches to all non-exempt real and/or personal property of the above-named obligor which is located or existing within the State/county of filing, including any property specifically described below.

Specific description of property:

(12)

All aspects of this lien, including its priority and enforcement, are governed by the law of the State where the property is located. An obligor must follow the laws and procedures of the State where the property is located or recorded. An obligor may also contact the entity sending the lien. This lien remains in effect until released or withdrawn by the issuing agency, the obligee, the entity acting on behalf of the obligee, or in accordance with the laws of the State where the property is located.

Note to Lien Recorder: Please provide the sender with a copy of the filed lien, containing the recording information, at the address provided above. (12a)

Check either “A” or “B” below. The option that does not apply may be omitted from the form.

If “B” is checked, the form must be notarized.

A. [(13) ] Submitted by a IV-D agency/office on behalf of the named obligee

As an authorized agent of a State or Tribal, or subdivision of a State or Tribal, agency

responsible for implementing the child support enforcement program set forth in Title IV, Part D, of the Federal Social Security Act (42 U.S.C. 651 et seq.), I have authority to file this child support lien in any State, or U.S. Territory. For additional information regarding this lien, including the pay-off amount, please contact the authorized agency and reference its case number, both listed above.

____(14)______ ________(15)___________________

Date Authorized Agent

_____________________________

Print name, e-mail address, phone and fax number

B. [ (16) ] Submitted by an obligee or a private (non-IV-D) attorney or entity on behalf of an obligee

I am [ ] the obligee of the above referenced order [or]

[ ] an attorney or entity representing the above named obligee

I certify under penalty of perjury that the information contained in this notice is true and accurate and that this lien is submitted in accordance with the laws of the State of _________________. For additional information regarding this lien, including the pay-off amount, please contact the obligee listed above.

___(14)_________ _____________(17)_________________

Date Signature

_______________________________

Print name, e-mail address, phone and fax number

Notary State:___________(18)_____________

County:__________(18)_____________

I certify that __________________________ appeared before me and is known to me as the individual who signed the above.

Date: _________ _______________________

Notary Public

My appointment expires __________________

Notice: Respondents are not required to respond to this information collection unless it displays a valid OMB

control number. The average burden for responding to this information collection is estimated at 30 minutes. If you believe this estimate is inaccurate, or if you have ideas to reduce this burden, please provide comment to the issuing agency.

OMB Control #: 0970-0153 Expiration Date: 02/28/2014 (Please note, this expiration date is for the OMB form and not the lien itself.)

Instructions for the Notice of Lien

Purpose of This Form: 42 USC 654(9)(E) requires all IV-D programs to use the Notice of Lien form in interstate cases. IV-D programs may also use the form to impose liens in intrastate

cases. This form may also be used for non-IV-D orders by an obligee or his or her private attorney. This form may be used to assert liens on assets discovered through the Financial Institution Data Match process. Please note that the expiration date on this form is the Office of Management and Budget expiration date, not the expiration date of the lien itself.

Whose Laws Apply?: All aspects of this lien, including its priority and enforcement, are governed by the law of the State where the property is located. Issue the lien to secure debts for past-due support upon identifying, in another State, nonexempt real or personal property belonging to the obligor. The laws and procedures of the State where the property is located or recorded determine which office or entity in that State is the appropriate one to receive the lien for filing. It is the responsibility of the agency/office or private attorney issuing the lien to file it with the appropriate entity.

Release of Lien: To release a previously-filed lien (e.g., upon receipt of full payment, or partial payment with an acceptable agreement to repay remaining balance, etc.,) the original issuing State shall use its existing local release of lien form. A copy of the release of lien should be provided to the obligor. Identify the lien to be released by including the recording information provided by the office or entity that filed the lien (Lien Recorder). The laws and procedures of the State where the lien is filed control the release of the lien.

To complete this form:

1. In the “TO” field place the name and address of the recorder (i.e., County Auditor, Clerk of Court, DMV, etc.) or asset holder (i.e., Financial Institution, Estate Executor, Trustee, etc.) to which you are sending the lien.

NOTE: The procedures of the State where the property is located determine which person or entity in that State is the appropriate one to receive the lien for filing. It is the responsibility of the person/entity/agency submitting the lien to file/serve it correctly.

2. In the “OBLIGOR” field place the obligor's full name, address, date of birth (if known) and social security number (if known). Include known aliases or multiple social security numbers used by the obligor.

3. In the “FROM” field insert the name, address, e-mail address and phone/fax numbers of the person or entity that is submitting this lien.

4. In the “OBLIGEE” field insert the obligee’s full name. Note that the obligee may be the individual obligee, a public IV-D agency, or a private attorney, person or entity with a proper assignment from the individual obligee.

5. In the “IV-D Case #” field, enter the number/identifier identical to the one submitted on the Federal Case Registry, which is a left-justified 15-character alphanumeric field, allowing all characters except asterisk and backslash, and with all characters in uppercase. For non-IV-D cases, enter the docket number in this field.

6. In the space following “entered on”, insert the date of entry of the order that is the basis for the lien. Verify that you are entering the correct date for the order that is being used to determine the amount of the lien.

7. In the space following “by”, identify the tribunal that issued the support order that is being used to determine the amount of the lien. A tribunal is a court, administrative agency, or quasi-judicial entity that has the authority to establish, enforce, and modify child support obligations.

8. In the space following “in”, identify the location (State/county) of the tribunal that issued the support order that is being used to determine the amount of the lien.

9. In the space following “tribunal number”, identify the tribunal docket, jacket or file number of the support order that is used to determine the amount of the lien.

NOTE: Instructions 6, 7, 8 and 9 should reference the same order.

10. In the space following “As of”, insert the date of the debt calculation that is used in determining the amount of the lien.

11. In the space following “amount of $”, insert the lien amount (the amount of the past-due support obligation owed when the lien is prepared). Interest may be included in the lien amount.

NOTE: If a notice of lien for one obligor is being submitted on behalf of multiple obligees, repeat the information in fields 6-11 as needed and also include the cumulative arrears for all cases.

12. In the space following “Specific description of property”, identify any specific property that you want the lien to attach to. Use the legal description of real property and, when the target of the lien is personal property, always provide the most specific identifying information available, including the location of the property, if known. (For example, include the make/model/year/appropriate registration numbers (if known), as opposed to referring to such personal property as “farm equipment”). For Financial Institutions, list the account numbers.

12a. Since all liens are not recorded and returned to the sender only follow this instruction if applicable.

13. Check “A” if the lien is submitted by a IV-D agency and check “B” if the lien is submitted

by an obligee or his or her private attorney.

14. Provide the date the lien is signed on the line provided above “date”.

15. If “A” is checked, the appropriate individual should sign the lien on the line above “Authorized Agent”. Type or print the name of the agent signing the lien below their signature. Include the agent’s name, e-mail address (if available) and phone and fax numbers. If “A” is checked, the form does not need to be notarized. Note that, in IV-D cases, the pay-off amount will be available only from the IV-D agency.

16. If “B” is checked, the appropriate individual should sign the lien on the line above the two check boxes and should check the appropriate box. Type or print the name of the person signing the lien below their signature. Include the person’s name, e-mail address (if available) and phone and fax numbers.

17. If “B” is checked, the signature of the party signing the lien must be notarized.

18. In the spaces following “Notary State” and “County”, insert the name of the State and

County (if applicable) where the notary is commissioned.

19. Send a copy of the lien to the obligor at his/her last known address.