Court File No. STATE OF NORTH CAROLINA In The General Court Of Justice County District Court DivisionName Of Plaintiff VERIFIED STATEMENT AND NOTICE OF VERSUS LIEN FOR DELINQUENT CHILD SUPPORT Name Of Defendant (NON-IV-D CASES) G.S. 44-86, 44-87 VERIFIED STATEMENT OF LIEN Name Of Obligor Date Of Child Support Order Amount Of Child Support Delinquent Amount Of Child Support Order $ as of (date) $ per NOTE: Delinquency must be at least $3,000 or the amount of child Month Semi-Monthly Bi-Weekly Weeklysupport owed for a period of three (3) months, whichever is less. Other I, the undersigned obligee, being first duly sworn, say that I have read the Verified Statement And Notice Of Lien For Delinquent Child Support and that the contents are true to my own knowledge, except as to matters stated on information and belief, and as to those, I believe them to be true. Date SWORN AND SUBSCRIBED TO BEFORE ME Date Signature Of Obligee Signature Name Of Obligee (Type Or Print) Address Of Obligee Deputy CSC Assistant CSC Clerk of Superior Court Date My Commission Expires SEAL Notary NOTICE OF FILING TO THE OBLIGOR NAMED ABOVE: You are hereby notified that the above Verified Statement And Notice Of Lien For Delinquent Child Support has been filed in the office of the Clerk of Superior Court in the county named above. A lien for delinquent child support, in the amount shown in the Verified Statement, may be docketed against real and personal property that you own and enforced by execution in the same manner as for a civil judgment. You may contest the validity of this lien by requesting a hearing before a district court judge within thirty (30) days from the date you are served with this Notice. If you fail to request a hearing within thirty (30) days, the obligee may request the Clerk of Superior Court to record and index the lien on the judgment docket and to issue a transcript of the docketed lien to other counties in which you may own property. If the lien for delinquent child support is docketed against your property, it may be discharged if you deposit with the Clerk of Superior Court money equal to the amount of the lien and request a district court judge to determine the validity of the lien, if the obligee files with the Clerk of Superior Court an acknowledgment that you have satisfied the full amount of the lien, or if the obligees action is dismissed or judgment is entered against the obligee. INSTRUCTIONS TO CLERK Do not docket this lien as a judgment against the obligor until (1) the Court enters an order confirming the lien and ordering that it be docketed as a judgment, or (2) the obligor fails to request a hearing to contest the lien within the time allowed by law and the obligee requests that the lien be docketed as a judgment. Date Lien Docketed Judgment Book And Page No. Abstract No.Signature Deputy CSC Assistant CSC Clerk of Superior Court AOC-CV-917M, Rev. 9/03 2003 Administrative Office of the Courts (Over) >>>> 2 RETURN OF SERVICE I certify that this Verified Statement and Notice was received and served as follows:Date Served Name Of Obligor By delivering to the obligor named above a copy of this Motion and Notice. By leaving a copy of this Motion and Notice at the dwelling house or usual place of abode of the obligor named above with a person of suitable age and discretion then residing therein.Name And Address Of Person With Whom Copies Left Other manner of service: (specify) The obligor WAS NOT served for the following reason: Date Received Signature Of Deputy Sheriff Making ReturnDate Of Return Name Of Sheriff (Type Or Print)Service Fee County Of Sheriff Paid Due $ AOC-CV-917M, Side Two, Rev. 9/03 2003 Administrative Office of the Courts