RCW 43.20B.040: Chapter does not apply where another party liable—Statement of lien—Form.

The form of the lien in RCW 43.20B.060 shall be substantially as follows:

STATEMENT OF LIEN

Notice is hereby given that the State of Washington, Department of Social and Health Services, has rendered assistance or provided residential care to . . . . . ., a person who was injured on or about the . . . . day of . . . . . . in the county of . . . . . . state of . . . . . ., and the said department hereby asserts a lien, to the extent provided in RCW 43.20B.060, for the amount of such assistance or residential care, upon any sum due and owing . . . . . . (name of injured person) from . . . . . ., alleged to have caused the injury, and/or his or her insurer and from any other person or insurer liable for the injury or obligated to compensate the injured person on account of such injuries by contract or otherwise.

STATE OF WASHINGTON, DEPARTMENT

OF SOCIAL AND HEALTH SERVICES

By: . . . . (Title)

STATE OF WASHINGTON

COUNTY OF

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ss.

I, . . . . . ., being first duly sworn, on oath state: That I am . . . . . . (title); that I have read the foregoing Statement of Lien, know the contents thereof, and believe the same to be true.

. . . .

Signed and sworn to or affirmed before me this . . . . day of . . . . . ., (year) . . . .

by . . . .

(name of person making statement).

(Seal or stamp)

. . . .

Notary Public in and for the State

of Washington

My appointment expires: . . . .