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Deputy CSC Assistant CSC Clerk Of Superior Court Deputy CSC Assistant CSC Clerk Of Superior Court STATE OF NORTH CAROLINA Court File No. (Over) County In The General Court Of Justice District Court Division A OC-CV -9 1 7 M , Rev . 9 / 0 3 © 2 0 0 3 A dminist rat iv e Of f ice of t he Court s Month Other Amount Of Child Support Delinquent VERIFIED STATEMENT OF LIEN I, the undersigned obligee, being first duly sworn, say t hat I have read the Verified Statement And Notice Of Lien For Delinquent Child Support and that the contents are tr ue to my own knowledge, except as to matters stated on in formation and belief, and as to those, I believe them to be true . SWORN AND SUBSCRIBED TO BEFORE ME Date Date Name Of Obligee (Type Or Print) Signature Of Obligee Address Of Obligee Name Of Obligor Date Of Child Support Order Amount Of Child Support Order $ as of (date) NOTE: Delinquency must be at least $3,000 or the amount of child support owed for a period of three (3) months, whichever is less. $ per Semi-Monthly Bi-Weekly Weekly SEAL Date My Commission Expires VERIFIED STATEMENT AND NOTICE OF LIEN FOR DELINQUENT CHILD SUPPORT (NON-IV-D CASES) G.S. 44-86, 44-87 VERSUS Name Of Defendant Name Of Plaintiff TO THE OBLIGOR NAMED ABOVE: You are hereby notified that the above Verified State ment 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 sho wn in the Verified Statement, may be docketed against r eal 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) da ys, the obligee may request the Clerk of Superior Court to record and index the lien on the judgment docket and to issue a tr anscript of the docketed lien to other counties in which yo u may own property. If the lien for delinquent child support is docketed aga inst your property, it may be discharged if you deposit wit h 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 S uperior Court an acknowledgment that you have satisfied t he full amount of the lien, or if the obligee's action is dismissed or j udgment is entered against the obligee. INSTRUCTIONS TO CLERK Do not docket this lien as a judgment against the obligo r 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 Signature Signature NOTICE OF FILING Abstract No. Judgment Book And Page No. Notary RETURN OF SERVICE AOC-CV-917M, Side Two, Rev. 9/03 © 2003 Administrative Office of the Courts Other manner of service: (specify) 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 residi ng therein. By delivering to the obligor named above a copy of this M otion and Notice. I certify that this Verified Statement and Notice was received and served as follows: Name And Address Of Person With Whom Copies Left The obligor WAS NOT served for the following reason: Date Served Name Of Obligor Date Received Date Of Return Service Fee $ Paid Due Signature Of Deputy Sheriff Making Return Name Of Sheriff (Type Or Print) County Of Sheriff