1 Notice of Lien

OMB# 0970 – 0152

Expiration Date: xx/xx/2027

NOTICE OF LIEN

The information on this form may be disclosed as authorized by law.

If you are not the intended recipient, you are hereby notified that any use, disclosure, distribution,

or copying of this form or its contents is strictly prohibited.

To: (Recorder or Asset Holder Name and Address)

File Stamp

Obligor: Legal Name (first, middle, last, suffix )

Alias Name(s)

Address

Date of Birth

Social Security Number

From: (Agency or name of obligee and/or his or her private attorney or entity acting on behalf of the obligee, address, telephone, e-mail address, fax )

Obligee Name(s):

Section I. Case Identifier:

1.

IV-D Case Number or Non-IV-D Docket Number:

Remittance ID or other payment identifier (optional):

2.

IV-D Case Number or Non-IV-D Docket Number:

Remittance ID or other payment identifier (optional):

3.

IV-D Case Number or Non-IV-D Docket Number:

Remittance ID or other payment identifier (optional):

Section II. Lien Notice:

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

Date

________________________________ in_________________________________ tribunal number ________________________.

Issuing Tribunal (name)

Location (state/county)

Support order

As of _____________, the obligor owes unpaid support in the amount of $ ______________.

Date

Lien amount

This judgment may be subject to interest, penalties, fees, surcharge, or other related amounts. (See Section 466(a)(4) of the Social

Security Act regarding Full Faith and Credit.)

Prospective amounts of child support, not paid when due, are judgments that are added to the lien amount. Contact the child

support agency or the obligee and/or his or her private attorney or entity acting on behalf of the obligee according to the contact

information located in the heading to obtain the current lien amount.

This lien attaches to all nonexempt: [ ] real property or [ ] personal property or [ ] real and personal property of the

above-named obligor, which is located or existing within the state/county where it may be filed, if required under state law. This

includes any property specifically described on the next page.

Barcode

The Paperwork Reduction Act of 1995 (Pub. L. 104-13): STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to provide uniformity and standardization in the transmission of interstate liens.  Public reporting burden for this collection of information is estimated to average .50 hours per form, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This collection of information is required for interstate cases (section 454(9)(E) of the Social Security Act).  An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0152 and the expiration date is xx/xx/2027. If you have any comments on this collection of information, please contact OCSS by email at [email protected].

NOTICE OF LIEN, PAGE 2

Section III. Property Description:

[ ] Continued on attached sheet(s), incorporated by reference

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 issuer 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.

Section IV. Remit Payment:

To remit payment, include the case ID, docket number, remittance ID or other payment identifier with the payment and, if

necessary, use this locator code:___________________.

Remit payment to:_____________________________________________________________________________________

[ ] SDU

[ ] Obligee

[ ] Obligee representative

At this address:________________________________________________________________________________________

Section V. Submission Entity:

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

As an authorized agent of a state or tribal agency (or subdivision of such) responsible for implementing the child support

services program set forth in Title IV, Part D, of the Social Security Act (section 451 et seq.), I have authority to file

this child support lien in any state. For additional information regarding this lien, including the pay-off amount,

please contact the authorized agency listed in the heading and reference its case number, listed in Section I.

Date

Authorized agent signature

Authorized agent printed name

E-mail

Direct telephone number

Fax

NOTICE OF LIEN, PAGE 3

Section V. Submission Entity (Continued):

[ ]

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

I am (choose one)

[ ]

the obligee of the above referenced order.

[ ]

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 or attorney/entity listed in the heading.

Date

Signature

Printed name

E-mail

Direct telephone number

Fax

Notary state

County

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

Date

Notary public

Appointment expiration

Section VI. Release of Lien:

This lien remains in effect, until released by issuer:______________________________________.

Printed name of issuer

As of ____________________, this lien has been satisfied or otherwise discharged and it is hereby effectively released.

Date

Date

Authorized agent signature

Authorized agent printed name

Encryption Requirements:

When communicating this form through electronic transmission, precautions must be taken to ensure the security of the data. Child support agencies are encouraged to use the electronic applications provided by the federal Office of Child Support Services. Other electronic means, such as encrypted attachments to e-mails, may be used if the encryption method is compliant with Federal Information Processing Standard (FIPS) Publication 140-2 (FIPS PUB 140-2).

INSTRUCTIONS FOR THE NOTICE OF LIEN

PURPOSE OF THE FORM:

The Social Security Act section 454(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.

Laws that 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 the appropriate office or entity in that state to receive the lien for filing. The agency/office or private attorney issuing the lien is responsible for filing it with the appropriate entity.

Release of lien:

To release a previously-filed lien (for example, upon receipt of full payment, or partial payment with an acceptable agreement to repay remaining balance) the original issuing state may use its existing local release of lien form. Alternatively, the issuer may use section VI of this form to release the lien. Provide a copy of the release of lien to the obligor. Identify the lien to be released by including the 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.

Italicized text that appears within a “box” refers to policy or provides additional information.

HEADING/CAPTION:

• The initiating jurisdiction/issuer determines the heading.

• In the “To” field place the name and address of the recorder (for example County Auditor, Clerk of Court, or DMV) or asset holder (for example Financial Institution, Estate Executor, or Trustee) to which you are sending the lien.

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.

• In the “Obligor” field place the obligor's full name, alias name(s), address, date of birth (if known) and Social Security Number (if known). Include known aliases or multiple Social Security Numbers used by the obligor.

• In the “From” field insert the issuer information, such as, the IV-D Agency name or name of the obligee and/or his or her private attorney or entity acting on behalf of the obligee, address, telephone number, e-mail address, and fax number of the person or entity that is submitting this lien.

• In the “Obligee Name” field insert the obligee’s full name. Multiple names can be listed. 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.

Section I. Case Identifier:

• In the space following “IV-D Case Number or Non-IV-D Docket Number”, for a IV-D case, 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 a non-IV-D case, enter the Non-IV-D tribunal docket, or jacket number or file number of the support order that is used to determine the amount of the lien.

• The Remittance ID is an optional field, (in some instances, this number may be the same as the IV-D case number or non-IV-D Docket number) and can be used when there is another identifier for payment remittance. However, the remittance ID is needed when the issuer is providing information in section IV.

Section II. Lien Notice:

• 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.

• In the space following “by”, identify the tribunal that issued the support order determining 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.

• In the space following “in”, identify the location (state/county) of the tribunal that issued the support order that is the basis of the lien.

• In the space following “tribunal number”, identify the tribunal docket, jacket or file number of the support order that is the basis of the lien.

• In the space following “As of”, insert the date of the debt calculation that is used to determine the amount of the lien.

• In the space following “amount of $”, insert the lien amount (the amount of the past-due support obligation owed when the lien is prepared). You may include interest or other related amounts in the lien amount.

• Choose the appropriate check box to indicate the type of property the lien will be attached to: “real property” or “personal property” or “real and personal property”.

If a notice of interstate lien for one obligor is being submitted on behalf of multiple obligees, repeat the information in Section II as needed and also include the cumulative arrears for all cases.

Barcode:

• If available, entities using imaging technology can use this area to add a barcode to the document.

Section III. Property description:

• In the space following “Property description”, identify any specific property that you want the lien to attach to.

• Use the legal description of real property. When the target of the lien is personal property, 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, rather than generic terms such as “farm equipment”.)

• For financial accounts, list the account numbers.

  

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

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

Section IV. Remit Payment:

• In the appropriate space, enter the locator code if necessary.

• In the space marked “Remit payment to:” list the name and select whether it represents an SDU, Obligee, or Obligee Representative.

• Add the address (street, PO Box, city, state, and zip code) of where payments are sent.

Section V. Submission Entity:

• 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.

• If “A” is selected, provide the date the lien is signed by the child support authorized agent on the line provided.

• If “A” is selected, the appropriate individual should sign the lien on the line above “Authorized Agent”. Type or print the name of the agent signing the lien beside their signature. Include the agent’s e-mail address (if available), direct telephone number and fax number. If “A” is checked, the form does not need to be notarized.

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

In IV-D cases, the pay-off amount will be available only from the IV-D agency.

• If “B” is selected, the appropriate individual should select the appropriate box next to “choose one”. Type or print the name of the person signing the lien next to their signature. Include the person’s e-mail address (if available), direct telephone number, and fax number.

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

• Include the “Notary state” and “County”, insert the name of the state and county (if applicable) where the notary is commissioned.

• Enter the date, notary public name, and appointment expiration.

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

Section VI. Release of Lien:

The Lien must be released by the IV-D Agency or the obligee and/or his or her private attorney or entity acting on behalf of the obligee who issued the lien.

• In the “Printed Name of Issuer” field, enter the IV-D Agency name or name of the obligee and/or his or her private attorney or entity acting on behalf of the obligee.

• In the space following “As of”, enter the effective date of the release of the lien.

• Place the date the Notice of Lien Release is signed in the “Date” field.

• The person issuing the Notice of Lien Release signs in the “Authorized Agent Signature” field and prints their name in the “Authorized Agent Printed Name” field.

Encryption Requirements:

When communicating this form through electronic transmission, precautions must be taken to ensure the security of the data. Child support agencies are encouraged to use the electronic applications provided by the federal Office of Child Support Services. Other electronic means, such as encrypted attachments to e-mails may be used if the encryption method is compliant with Federal Information Processing Standard (FIPS) Publication 140-2 (FIPS PUB 140-2).

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