Original - Court 1st copy - Debtor Approved, SCAO 2nd copy - Department of Treasury STATE OF MICHIGAN CASE NO. JUDICIAL CIRCUIT - FAMILY DIVISION ORDER TO CANCEL PETITION NO. COUNTY STATE INCOME TAX INTERCEPT Court address Court telephone no.1. In the matter of (name(s), alias(es)) THE COURT FINDS: 2. On this court entered an order directing the Michigan Department of Treasury to withhold up to Date $ of any state income tax refund due to First, middle initial, and last name and social security no. First, middle initial, and last name and social security no. Address Address City, state, zip City, state, zip to reimburse the court for costs of care and/or services assessed in the above matter which had become delinquent. in full $ on . 3. The above person(s) paid Date in part $ on . Date 4. Other: 5. IT IS ORDERED the order to intercept state income tax is cancelled and the Michigan Department of Treasury shall delete the order from its records. Date Judge Bar no. CERTIFICATE OF MAILING I certify that on this date copies of this order were served upon the person(s) named above by ordinary mail at their last known addresses. Date Signature Do not write below this line - For court use only JC 62 (6/03) ORDER TO CANCEL STATE INCOME TAX INTERCEPT MCL 712A.18(2), MCL 769.1(7)