State of Michigan department of HEALTH AND human services Lansing GRETCHEN WHITMER governor ELIZABETH HERTEL director
Date:
To:	(Financial Institution Name)
(Street Address)
(City, State, Zip)
Re:	Other State’s Notice of Lien
Name of obligor	Social Security number	Obligor’s date of birth
IV-D case number(s)	County issued in	State issued in
Please find the attached Notice of Lien in reference to the above-named obligor/account holder. We appreciate your financial institution’s cooperation in this matter.
This Notice of Lien was received by our office on	.
The Michigan Office of Child Support Central Operations has completed its review of this Notice of Lien packet and affirms that it fully complies with Michigan statutory requirements. This lien is therefore entitled to full faith and credit under Michigan Compiled Law 552.625c and United States Code 666(4).
Due process will be afforded to the account holder under §	of the	State Law.
This Notice of Lien directs the financial institution to restrict/freeze any funds, up to	$	.
The	(other state’s child support [IV-D] agency) will contact the financial
institution when the funds should be levied, or released to the State of	,
based on the resolution of the lien.
All questions regarding this lien should be directed to:
Name of contact person	Other state’s child support (IV-D) agency
Telephone number	Fax number
Thank you for your cooperation in this matter. Michigan Office of Child Support Central Operations
The Michigan Department of Health and Human Services will not exclude from participation in, deny benefits of, or discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, gender identification or expression, sexual orientation, partisan considerations, or a disability or genetic information that is unrelated to the person’s eligibility.

For the Issuing Agency Only:
PROOF OF SERVICE: As required by MCR 2.104(A)(3), I certify that a copy of the attached Notice of
Lien was sent to the financial institution named above, on this day,	,
and time	a.m./p.m. via:
Fax to the following number:	.
First-class mail to the address shown below: Office of Child Support Central Operations PO Box 30744 Lansing, MI 48909-8244 Phone: 517-241-8507 Fax: 888-600-1585
I declare that the statements above are true to the best of my information, knowledge, and belief.
Signature and Title	Date