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Child Support Division
Special Collections Unit

Response to Insurance Claim Notice

Response to Notice

Withholding has been placed on the periodic benefits the claimant will receive

A Lien has been placed on any possible settlement the claimant will receive

The Withholding and/or Lien can not be placed for the following reason(s):

Attorney Information (if known)

Claimant is not represented by Counsel

Claimant is represented by Counsel:

Employer Information (if known)

Completed by:

Adjuster Attorney