Approved, SCAO STATE OF MICHIGAN CASE NO. JUDICIAL CIRCUIT REQUEST FOR TAX REFUND OFFSETS COUNTY Federal and state law provide for collecting overdue child support from tax refunds of persons (payers) ordered to pay support.If you want us to try to collect support owed to you from the payers tax refunds, you must agree to the conditions listed below.You must also provide us with current information about yourself, the payer, and the child(ren). Please read the following conditionscarefully. If you decide you want this service, fill in the form on the other side of this notice, sign it, and return it as follows: BY: TO: Friend of the Court Do NOT return the form if you do NOT want us to collect support owed to you from the payers tax refund. CONDITIONS 1. There is no guarantee that monies will be collected on my behalf from tax refunds. 2. To collect support from a STATE tax refund, past due child or child and spousal support must be at least $300.00.3. To collect support from a FEDERAL tax refund, support arrearages owed to me must be at least $500.00. The overdue support must be owed for a child under age 18. 4. If I ever received ADC, I assigned to the state rights to support due me while on assistance. Overdue support may still be owed to the state to repay past ADC arrearages. I understand that any tax refunds that are intercepted will be applied to ADC arrearages before any collection is sent to me. 5. I understand that the payer may also owe other debts to the state or federal government. Those depts will be paid from tax refunds first. Any remaining portion of the payers tax refund may be paid to me. 6. The Friend of the Court may hold support collected from federal joint tax refunds for six months before sending the money to me. This provides payers new spouse an opportunity to file for his/her share of the tax refund. 7. I understand that I am personally liable for the return of any amounts received by me which were paid in error, including any amounts which must be returned due to filing of an amended return by the payers spouse. FOC 32 (8/86) REQUEST FOR TAX REFUND OFFSETS >>>> 2 REQUEST FOR TAX REFUND OFFSETS A. RECIPIENT INFORMATION 1. Your name 2. Home telephone no. 3. Social security no.4. Current address CityState Zip 5. Employer 6. Work telephone no.7. Have you ever received ADC? Yes No If yes, where? When? B. PAYER INFORMATION 1. Payers name 2. Home telephone no. 3. Social security no.4. Current address CityState Zip 5. Employer 6. Work telephone no. 7. Is the payer married? Yes NoC. CHILDREN INFORMATION NAMES DATES OF BIRTH ACKNOWLEDGMENT I request Title IV-D child support services including collection of past due support from the payers tax refund. I understand andagree to all of the conditions specified in this notice. The information on this form about myself, the payer, and the child(ren) is trueand correct to the best of my knowledge. annual offset. (a new offset request must be completed each year). This request is for ongoing offset. (the request remains in effect until termination is requested, the account is paid in full, or the arrearage falls below an established cutoff level). Date Signature