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STATE OF C ALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY <br />CALIFORNIA DEPARTMENT OF SOCIAL SERVICES <br />XII <br />rn <br />n C) <br />M <br />4=, <br />c�a <br />n cn <br />o <br />RECORDING REQUESTED BY: <br />COUNTY OF SACRAMENTO, DRR <br />C <br />Z <br />tDn <br />n _ <br />�L <br />c D <br />rn <br />N <br />rn <br />�- <br />10669 COLOMA ROAD = n <br />D <br />v <br />Fri <br />o <br />ro <br />RANCHO CORDOVA A 95670 'n CA <br />916 -875 -7500 <br />Ty "V � <br />d <br />m <br />�„ <br />s rn <br />ca <br />D <br />ENTO <br />�. <br />DEPARTMENT OF REVENUE RECOVER <br />4 <br />3 <br />N <br />N <br />10669 COLOMA ROAD <br />L0 <br />Cn <br />n <br />`"' <br />�` <br />FwillY�r @�� t li/i B9�fki1�' CONTA <br />(^j <br />(n <br />� <br />� <br />CD <br />, vr1 ��77 �0 f� lU1 <br />N <br />� <br />z <br />LIEN <br />On this -_ day of ___ -J�i_�_________, 20 �? 3, I, <br />1 �q\.jxy E� <br />UNDEF.SIGNED) <br />grant the COUNTY of ___ f1tV , a political subdivision of the State of California, a lien against the real <br />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 <br />County of--_S tyajA e because of the agreement signed on _____ ' �S~ ��� ______, for myself, my spouse, <br />or my children beginning the __ -_ day of ___ J 11� ---------- 12003 <br />. <br />I hereby waive the defense provided by the statute of limm6ations. <br />This lien is binding upon myself, my heirs, executors, administrators, and assignees. <br />The following is a true and correct description of the real property owned by me or in which I have an interest: <br />(Attach additional pages if necessary) LOT 72 AND THE SOUTH 25 FEET OF LOT .75 IN WEST LAWN AND <br />ADDITION TO THE CITY OF ISLAND <br />NAME S) OF OWNER(S) AS IT APPEARS ON THE COUNTY TAX ASSESSOR'S ROLLS <br />�tG u L1 t o G <br />THE AUTHORITY FOR THIS LIEN IS FOUND IN WELFARE AND INSTITUTIONS (W &I) CODE 11257.5 <br />SIGNATURE OR MARK DATE PRINTED NAME IN FULL <br />7 mc oc &y r, t 44 i NG u YEiV <br />SIGNATURE OR lAkIAF AA SE <br />DATE I SPOUSE'S PRINTED NAME IN FULL <br />SIGNATURE OF WITNESS TO MARK(S) <br />NOTARIZATION <br />STATE OF CALIFORNII <br />COUNTY OF <br />On - ���) - -- before me, <br />itl �Ahhd Name of Office) `� <br />personally appeared _1_�! �� (((� 11 i1 /___L V`lz__ 7 _ <br />personally known to me (or proved to me on the basis of satisfactory evidence) to be the <br />person(s) whose name(s) is /are subscribed to the within instrument and acknowledged to me <br />that he /she /they executed the same in his /her /their authorized capacity(ies), and that by <br />his /her /their signature(s) on the instrument the person(s), or the entity upon behalf of which the <br />person(s) aqjedrexecutQdAe instrument. <br />WITNESS <br />Signature <br />CW 81 (7/01) REQUIRED FARM - SVBSTITUIIES PERMITTED <br />OA'E <br />SEAL <br />