STATE OF CALIFORNIA— HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
FOR RECORDER’S USE
RECORDING REQUESTED BY:
WHEN RECORDED MAIL TO:
FOR THE AMOUNT OF THE LIEN BALANCE CONTACT:
LIEN
On this_______ day of ______________________, 20____, I, _____________________________________________________________,
(THE UNDERSIGNED)
grant the COUNTY of ____________________________________, a political subdivision of the State of California, a lien against the real
property owned by me or in which I have an interest as described below. This lien is granted as security for the amount I owe the
COUNTY of___________________________ because of the agreement signed on __________________________, for myself, my
spouse,
or my children beginning the _______ day of _________________________, 20____.
I hereby waive the defense provided by the statute of limitations.
This lien is binding upon myself, my heirs, executors, administrators, and assignees.
The following is a true and correct description of the real property owned by me or in which I have an interest:
(Attach additional pages if necessary)
NAME(S) OF OWNER(S) AS IT APPEARS ON THE COUNTY TAX ASSESSOR’S ROLLS
THE AUTHORITY FOR THIS LIEN IS FOUND IN WELFARE AND INSTITUTIONS (W&I) CODE 11257.5
SIGNATURE OR MARK
DATE
PRINTED NAME IN FULL
SIGNATURE OR MARK OF SPOUSE
DATE
SPOUSE’S PRINTED NAME IN FULL
SIGNATURE OF WITNESS TO MARK(S)
DATE
NOTARIZATION
SEAL
STATE OF CALIFORNIA
COUNTY OF ___________________________
On _______________ before me, ______________________________________________ ,
(Title and Name of Officer)
personally appeared ___________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s)
is/are subscribed to the within instrument and acknowledged to me that he/she/they executed
the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the
instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the
instrument.
I certify, under PENALTY OF PERJURY under the laws of the State of California that the
foregoing paragraph is true and correct.
WITNESS my hand and official seal,
Signature ____________________________________________________________________
CW 81 (4/10) REQUIRED FORM - SUBSTITUTES PERMITTED