| IN THE SUPERIOR COURT OF THE |
| STATE OF WASHINGTON IN AND FOR THE |
COUNTY OF . . . . . . . . . . .
|
| . . . . . . . . . . . . | No. | . . . . . . . . . . . . |
| Obligee | |
| vs. | |
| ANSWER TO |
| . . . . . . . . . . . . | MANDATORY BENEFITS |
| Obligor | ASSIGNMENT ORDER |
| . . . . . . . . . . . . | |
| Department of Retirement Systems of |
the State of Washington
|
| 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 |