| IN THE SUPERIOR COURT OF THE |
| STATE OF WASHINGTON IN AND FOR THE |
COUNTY OF . . . . . . . . . . .
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No. |
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| Obligee |
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| vs. |
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ANSWER TO |
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MANDATORY BENEFITS |
| Obligor |
ASSIGNMENT ORDER |
| . . . . . . . . . . . . |
|
| Department of Retirement Systems of |
the State of Washington
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| 1. At the time of the service of the mandatory benefits
assignment order on the department, was the above-named
obligor receiving periodic retirement payments from the
department of retirement systems? |
| Yes . . . . . . No . . . . . . (check one). |
| 2. At the time of the service of the mandatory benefits
assignment order on the department, had the above-named
obligor requested a withdrawal of accumulated
contributions from the department? |
| Yes . . . . . . No . . . . . . (check one). |
| 3. Are there any other court or administrative orders
on file with the department currently in effect directing the
department to withhold all or a portion of the obligor's
benefits? |
| Yes . . . . . . No . . . . . . (check one). |
4. If the answer to question one or two is yes and the
department cannot comply fully with the mandatory
benefits assignment order, provide an explanation.
|
I declare under the laws of the state of Washington
that the foregoing is true and correct to the best of my
knowledge.
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| Signature of director |
Date and place
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| or |
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| Signature of person |
Place |
answering for director
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| Connection with director |