| In Re: A Purported Lien | In the ________________ Judicial District | |
| or Claim Against | In and For __________ | |
| (Name of Purported | County, Kansas | |
| Debtor) |
| THE STATE OF KANSAS) ) COUNTY OF ) |
| In Re: A Purported Lien | In the ___________ Judicial District | |
| or Claim Against | In and For ________________ | |
| (Name of Purported | County, Kansas | |
| Debtor) |