Original - Court 1st copy - Debtor Approved, SCAO 2nd copy - Department of Treasury STATE OF MICHIGAN CASE NO. JUDICIAL CIRCUIT - FAMILY DIVISION ORDER TO INTERCEPT PETITION NO. COUNTY STATE INCOME TAX Court address Zip code Court telephone no. 1. In the matter of (name(s), alias(es)) THE COURT FINDS: 2. On this court entered an order directing Date First, middle initial, and last name Social security no. First, middle initial, and last name 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. The balance owing as of is $ . The account is delinquent $ . Date 3. The above person(s) has/have failed to comply with the order of reimbursement and is/are delinquent. 4. A notice of intent to intercept state income tax was sent to on Name(s) . Date 5. IT IS ORDERED the Michigan Department of Treasury shall withhold up to $ of any state income tax refund due the above person(s) and shall forward the withholdings to: County/Court name Department/Address Address City, state Zip Telephone no. 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 61 (6/03) ORDER TO INTERCEPT STATE INCOME TAX MCL 712A.18(2), MCL 769.1(7)