IN THE ________ JUDICIAL CIRCUIT COURT, _______________________, MISSOURI Judge or Division: Case Number: Petitioner: MACSS Case ID: SSN (last four digits): DOB: vs. Respondent: SSN (last four digits): DOB: (Date File Stamp) Lien Request I, ____________________________________________________________________ am legally entitled to the arrearages which have accrued under an order entered by: The Circuit Court of _________________________________ (County/City of St. Louis), Missouri. The Director of the Division of Child Support Enforcement, State of Missouri and filed in the Circuit Clerk’s Office of _______________________________ (County/City of St. Louis), Missouri. Pursuant to Section 454.515 RSMo., please effect a lien on the real estate of _____________________________________, obligated to pay the support under the order. Check if applicable. Attached is a sworn affidavit of arrearages. Attached is a certified copy of the order of support (transcript of judgment). ___________________________________________ Date OSCA (10-01) CS30 ____________________________________________ Applicant Signature 1 of 1 454.515 RSMo American LegalNet, Inc. www.FormsWorkFlow.com