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.

. . . .

. . . .

Signature of director

Date and place

or

. . . .

. . . .

. . . .

Signature of person

Place

answering for director

. . . .

Connection with director