Skip to main content
Find a Lawyer

Washington Revised Code Title 43. State Government--Executive § 43.20B.040. Chapter does not apply where another party liable--Statement of lien--Form

Current as of January 01, 2025 | Updated by Findlaw Staff

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

)

)

ss.

COUNTY OF

)

    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: ․․․․․․․․․․․․․․․․․․․․․․․
Previous Part of Code Next Part of Code
Back to Chapter List

Cite this article: FindLaw.com - Washington Revised Code Title 43. State Government--Executive § 43.20B.040. Chapter does not apply where another party liable--Statement of lien--Form - last updated January 01, 2025 | https://codes.findlaw.com/wa/title-43-state-governmentexecutive/wa-rev-code-43-20b-040/

FindLaw Codes may not reflect the most recent version of the law in your jurisdiction. Please verify the status of the code you are researching with the state legislature before relying on it for your legal needs.

Was this helpful?

Welcome to FindLaw's Cases & Codes

A free source of state and federal court opinions, state laws, and the United States Code. For more information about the legal concepts addressed by these cases and statutes, visit FindLaw’s Learn About the Law.

Go to Learn About the Law

Latest Blog Posts

For Legal Professionals

Learn About The Law

Get help with your legal needs

FindLaw’s Learn About the Law features thousands of informational articles to help you understand your options. And if you’re ready to hire an attorney, find one in your area who can help.

Go to Learn About the Law

Need to Find an Attorney?

Search our directory by legal issue

Enter information in one or both fields (Required)

Copied to clipboard