NOTICE OF LIEN

VICTIM IDENTIFICATION FORM

TAKE NOTICE that on                                                                   ,  20           , an Order of Restitution was entered against defendant                                                                                    , in criminal case number                               , of  the          District Court /        Circuit Court,  for Lapeer County, Michigan.

TAKE FURTHER NOTICE  that as a result of that order, Mr. / Mrs.                                                                                            ,  has placed a LIEN on this property for  restitution in the amount of                                                   .

The address of the Lienholder is:

                        (No./Street/Apt.)

                        (City/State/Zip Code)

A Certified copy of the Judgment of Sentence containing the Order of Restitution is attached to this form. Certified copies of any additional Order(s) of Restitution are also attached hereto.  This Notice of Lien / Identification Form should be recorded together with the certified copy of the Judgement of Sentence and/or Order of Restitution at the Register of Deeds.

Signature of Lienholder                                                                                                        .

Dated:                                                                         .