DIRECT CREDIT Date: PAYER NAME: STREET ADDRESS: CITY, STATE, ZIP: ( ) _______ CASE NO. _____ EMPLOYER: STREET ADDRESS: CITY, STATE, ZIP: ( ) I, THE UNDERSIGNED , DO HEREBY AUTHORIZE THE FRIEND OF THE COURT TO CREDIT THE ABOVE CAPTIONED ACCOUNT AND SAID CREDIT IS TO BE APPLIED TO THE ARREARS BALANCE. NO ADDITIONAL DIRECT CREDITS WILL BE APPROVED FOR A MINIMUM OF 12 MONTHS. EFFECTIVE _____________ I WISH TO WAIVE ANY AND ALL ARREARS OWED DIRECTLY TO MYSELF, AND THE TOTAL AMOUNT WAIVED IS SUBJECT TO A REVIEW PRIOR TO CREDIT BEING ISSUED. -ORA CREDIT TO BE APPLIED AS FOLLOWS, FOR SUPPORT OWED DIRECTLY TO MYSELF, AND IS SUBJECT TO A REVIEW PRIOR TO CREDIT BEING ISSUED. $ $ $ CHILD SUPPORT MEDICAL SUPPORT CHILD CARE $ $ $ SPOUSAL SUPPORT OTHER ____ TOTAL CREDIT (Payee Initials) I AM NOT CURRENTLY RECEIVING CASH ASSISTANCE FROM THE STATE OF MI. CREDIT WILL NOT BE GRANTED (OR MAY BE REVOKED IF PREVIOUSLY APPROVED) IF PAYMENT WAS TENDERED DURING ANY TIME THE PAYEE WAS RECEIVING STATE ASSISTANCE WHERE AN ASSIGNMENT OF CHILD SUPPORT RIGHTS WAS GRANTED UNLESS SAID PAYMENTS WERE PROPERLY REPORTED TO THE DEPARTMENT OF HUMAN SERVICES OR ANY KNOWN OR SUBSEQUENTLY DISCOVERED OBLIGATION TO THE STATE OF MICHIGAN. SIGNED DRIVER LICENSE # AND STATE DATE ______________ ________________________________ SOCIAL SECURITY NUMBER *ADDRESS CITY ______________________ STATE ____________________ ZIP CODE__________________________ *If address different on system, the address provided will be updated as a legal mailing address. _____________________________________________ PAYEE PHONE NUMBER THIS FORM MUST BE NOTARIZED IF NOT SIGNED BEFORE A GENESEE COUNTY FOC EMPLOYEE SUBSCRIBED AND SWORN TO BEFORE ME THIS ______ DAY OF _______________________A.D., _____________ NOTARY PUBLIC, ________________, MI COMMISSION EXPIRES: -------------------------------------------------------------------------------------------------------------------------------------------------------FOR OFFICE USE ONLY INFORMATION TAKEN/VERIFIED BY________ Updated 06/2015 CASEWORKER APPROVAL BENCH WARRANT YES NO American LegalNet, Inc. www.FormsWorkFlow.com