Approved, SCAO Original - Court 1st copy - Defendant 2nd copy - Officer 3rd copy - Plaintiff STATE OF MICHIGAN JUDICIAL DISTRICT JUDICIAL CIRCUIT Court address Plaintiff's name(s) CASE NO. PAYMENT RECEIPT AND INVENTORY OF SEIZED PROPERTY Court telephone no. Defendant's name(s) v TO THE OFFICER SEIZING PROPERTY: This form must be filed with the court within 7 days of the payment of funds or seizure of property. RECEIPT FOR PAYMENT OF FUNDS 1. I collected $ 2. Payment was made by 3. a. b. c. d. e. f. g. on Date from check no. . money order/cashier's check no. . . cash. Balance due ....................................................................................................... $ Minus payment ................................................................................................... $ Statutory service and mileage fees .................................................................................................... Statutory percentage of line b fees : 7% of / 3% of . ........................................ Statutory expenses ............................................................................................................................ 0.00 Plus total of lines c, d, and e above .................................................................... $ New balance due* ............................................................................................ $ 0 $ $ $ *Additional statutory interest, fees (7% of first $8,000.00 and 3% of remaining balance), and expenses may be charged in addition to the unpaid balance. Attach additional sheets if necessary. INVENTORY OF PROPERTY SEIZED Item/Description/Model Type/V.I.N./Serial Number Quantity Real property seized (copy attached) . Property may be redeemed by payment in full of the judgment and all statutory fees and statutory expenses. If the property is not redeemed, it will be sold at public sale and the proceeds applied to the judgment according to law. For further information call the individual named below. I certify that I am authorized to seize property under MCR 3.106 and that the above statements are true and accurate. Date Signature Name (type or print) (Court officer/Deputy sheriff) Telephone no. MCR 3.106 MC 82 (4/14) PAYMENT RECEIPT AND INVENTORY OF SEIZED PROPERTY American LegalNet, Inc. www.FormsWorkFlow.com