DOMESTIC RELATIONS SECTION COURT OF COMMON PLEAS 29 W. CHERRY AVENUE, STE. 311 WASHINGTON, PA 15301 PART 1. OBLIGOR INFORMATION (To be completed by requestor) Please search your records of child and spousal support obligations to determine whether any record of overdue support exists for the following person: Name Date of Birth Social Security Number _______________________________ ________________________ _____________________ __________________________________________________________ Name and Title of Requestor __________________________________________________________ Company __________________________________________________________ Address __________________________________________________________ City State Zip Code **You MUST include your check payable to Washington County DRS in the amount of $10.00** PART 2. LIEN INFORMATION (To be completed by the DRS) ____________ We have no record of any case with the above-named individual. ____________ We have the following record of overdue support owed by the above-named obligor. This overdue support is a lien by operation of law against all real property owned by the obligor. Amount of Overdue Support Next Due Date Next Payment Amount _________________________ __________________ _____________________ Date: _____________________ BY: ___________________________________________ TITLE: ___________________________________________ (Seal) **THE ORIGINAL OF THIS DOCUMENT BEARS A RAISED COURT SEAL IN THE SPACE AT THE LEFT** American LegalNet, Inc. www.FormsWorkflow.com