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RECEIVED 11/20/2006 at 2:53 PM
RECEIVING # 924629
BOOK: 640 PAGE: 767
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER,Y~/'t.__,_
---~------- ------------------.--.--------..--..--.-----"':" --+ . -- . ,
NOTICE OF LIEN
TO: (Name/Address of recorder or asset holder)
LINCOLN COUNTY CLERK
925 SAGE AVE STE 101
KEMMERER WY 83101
Obligor: (Name/Address/DOB/SSN)
DONALD JEAN HACKLlN
PO BOX 391
LABARGE WY 83123
DOB: 3/31/1967
SSN: XXX-XX- 5275
Alias Name:
Alias SSN: XXX-XX-
Alias Name:
Alias SSN: XXX-XX-
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) .
WASHINGTON STATE DIVISION OF CHILD SUPPORT
PO Box 11520
TaComa WA 98411-5520
Phone: (360) 664-6900
E-mail: GHARRIS@DSHS. WA. GOV
Fax: (360) 438-8520
Obligee: (Name) SHONNA ELLEN ANDREWS
IV-D Case #: 1888080
NOTICE OF LIEN
DSHS 09-862 (REV. 0312005)
Page 1 of 3
FG VER: (1.3)
1250:09222006/
1888080 /1250
/
000768
This lien results from a child support order, entered on OS/24/1994
by DISTRICT COURT OF THE THIRD JUDICIAL DISTRICT
in WY / LINCOLN
tribunal number CIVIL 9289
As of 09/22/2006 ,the obligor owes unpaid support in the amount of $ 5 I 725 . 20
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:
ANY AND ALL PROPERTY OWNED BY DONALD JEAN HACKLIN OR IN WHICH HE HAS A
RECORDED INTEREST.
Ail 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lien remains in effect until released or withdrawn by the obligee or in accordance with the laws of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 "8" below. The option that does not apply may be omitted from the form. If
"8" is checked, the form must be notarized.
A. 00 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 0, 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 regardin -thrš'1iêñ~luding the pay-off
amount, please contact the authorized agency and reference i case number, both listed above.
September 22, 2006
Date
./.,
Authori~ent
."..~~...
.-
.....-- G HARR I S
GHARRIS@DSHS.WA.GOV
(360) 664-6900
(360) 438-8520
Print name, e-mail address, phone and fax number
NOTICE OF LIEN
DSHS 09-862 (REV. 03/2005)
Page 2 of 3
FG VER: (1.3)
1250:09222006/
1888080 / 1250
-_.__.~~---
000769
S. 0 Submitted by an obligee or a private (non-lV-D) attorney or entity on behalf of an obligee.
I am 0 the obligee of the above referenced order [or]
o 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
******************.***********.******.*.***.********************************************.***************.*****
State of Washington
County of: Thurston
I certify that G HARRIS appeared before me and is
known to me as the individual who signed the above. '"'
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Notice: Respondents are n~~&1freW~~~6nd to this information collection unless it displays a
valid OMS control number. The ~o/€fm'g~tburden 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.
OMS Control #: 0970-0153 Expiration Date: 01/31/2008
NOTICE OF LIEN
DSHS 09-862 (REV. 0312005)
Page 3 of 3
FG VER: (1.3)
1250:09222006/
1888080 / 1250