LIENS FOR CHILD SUPPORT CHAPTER 1240-2-5 (Rule 1240-2-5-.16, continued) STATE OF TENNESSEE DEPARTMENT OF HUMAN SERVICES Fax Type Name here Address City, State Zip NOTICE OF LIEN OBLIGOR: OBLIGEE: IV-D CASE #: This lien results from a child support order, entered on __ / __ / __ by __________ in ____________ County, TN, Tribunal Number ____________. As of __ / __ / __, the obligor owes unpaid support in the amount of $ _____. 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: 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 This lien remains in effect until released or withdrawn by the obligee or in accordance with the laws of the State where the property is located.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. October, 2005 (Revised) 1 American LegalNet, Inc. www.USCourtForms.com LIENS FOR CHILD SUPPORT CHAPTER 1240-2-5 (Rule 1240-2-5-.16, continued) 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, or subdivision of a State or Tribal, agency responsible for implementing the child support enforcement program set forth in Title IV, Part D, 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 regarding this lien, including the pay-off amount, please contact the authorized agency and reference its case number, both listed above. ______________________ Date _____________________________ Authorized Agent _______________________________________________________________________ Print name, e-mail address, phone and fax number B. [ ] Submitted by an obligee or a private (non-IV-D) attorney or entity on behalf of an obligee. I am: [ ] the obligee of the above referenced order [or] [ ] 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 Tennessee. 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 ******************************** October, 2005 (Revised) 2 American LegalNet, Inc. www.USCourtForms.com LIENS FOR CHILD SUPPORT CHAPTER 1240-2-5 (Rule 1240-2-5-.16, continued) Notary State: ___________________ County: _____________ I certify that _________________________ appeared before me and is known to me as the individual who signed the above. Date: ___________________________ ________________________________ Notary Public My appointment expires ____________ Notice: Respondents are not required to respond to this information collection unless it displays a valid OMB control number. The average burden 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. OMB Control #: 0970-0153 Expiration Date: 01/31/2008 October, 2005 (Revised) 3 American LegalNet, Inc. www.USCourtForms.com