Fill and Sign the Civ 570 Request to Return Pfd Taken by Mistake State of Form

09208 CIV-502 (2/10)(cs) Server Code – Date – Writ IN THE DISTRICT/SUPERIOR COURT FOR THE STATE OF ALASKA AT Writ of Execution and Notice of Levy on Permanent Fund Dividend by Certified Mail 1. Full Name of Judgment Debtor: First Last DOB SSN 2. Case Number Date of Judgment Case Name vs. Name of Judgment Creditor To: Department of Revenue Judgment creditor recovered a judgment against judgment debtor in this court in the amount shown below. This debt is for: child support ordered by the court or by a child support enforcement agency restitution ordered by a court in a criminal or delinquency case a defaulted Alaska education loan a court ordered fine a civil judgment (1) against a minor or (2) against a parent or legal guardian of an unemancipated minor for destruction of property by the minor under AS 34.50.020 a debt to a state agency a domestic violence rehabilitation program required by the court or a parole board other You are notified that the Alaska Permanent Fund dividend to which the debtor is entitled is levied upon and garnished in an amount not exceeding the total amount due listed below.* You are commanded to send to the clerk of the above-named court that portion of the dividend levied upon which is not exempt from execution. CLERK OF COURT BY: Date Deputy Clerk STATEMENT OF AMOUNT DUE as of Civil Rule 69(a), (f) & (i); AS 09.35.030 WRIT OF EXECUTION ON PFD AS 43.23.065; Adm. Bulletin 68 09208 (SEAL) Total Judgment Minus Amt. Paid to Date on Judgment - Balance ............................................................................ + Accrued Interest to October 15 ** Minus Amt. Paid to Date on Interest - Interest Balance .............................................................. + Accrued Costs (incl. cost of serving this writ: fee + postage) Minus Amt. Paid to Date on Costs - Costs Balance ................................................................ + *TOTAL AMOUNT DUE **Interest will be recalculated if any payments are received before the PFD is seized 0.00 0.00 0.00 $0.00