COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : IN THE CIRCUIT COURT OF Index No. COUNTY, MISSOURI : Debtor Name: -againstDebtor Address & Phone Number: : Case Number: Case Description: Plaintiff(s) Case Location: Calendar No. JUDICIAL SUBPOENA : Debtor Party ID: Debtor SSN: : Payment Plan Number: : Letter Number: (Date File Stamp) Defendant(s) Application for Review of Court Debt Offset : ...................................................... I, , (name) received notice from the Department ofRevenue of a court debt offset with my Missouri state tax refund due to the costs and/or fees and/or fines for the case listed above not being fully THE PEOPLE OF THE STATE OF NEW YORK . I am now applying for a satisfied. The date on the Notice of Court Debt Offset is TO review of this court debt offset because this debt was paid on GREETINGS: (date). Date Debtor Signature Instructions to Debtor WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before 1. If you have paid the debt owed to the Court for this case or if Court did not order you to pay, this written , the Honorable must be filed within 30 days of the date themailing on the Notice of Court Debt Offset with the court at of Court application located at Countyin which the debt is owed. The application must include: of in room Copies of on the and/or cancelled checks showing payment made to the court satisfying this and at any recessed , receipts day of , 20 , at o'clock in the noon, debt. a. or adjourned copy of the original Noticeevidence Debt witness in this action on the part of the b. A date, to testify and give of Court as a Offset. 2. A copy of this application must be sent to the Office of State Courts Administrator, Court Debt Offset Program, PO Box 104480, Jefferson City, MO 65110. Notice: Failure tofailure to comply with this court and send a copy to the Office of State Courts Administrator within liable to Your file this application with the subpoena is punishable as a contempt of court and will make you 30 days of the date of mailing on thesubpoena CourtissuedOffset that you received from the Missouri Departmentsustained as a the party on whose behalf this Notice of was Debt for a maximum penalty of $50 and all damages of Revenueof your deemed to waiver of the opportunity to contest the offset. result will be failure a comply. Results of Court Review of Debt Offset Action (To be completed by the Court.) Witness, Honorable , one of the Justices of the Court in County, day of , 20 Upon review of the debtor’s Application for Review of Court Debt Offset, the Court finds that the Office of State Courts Administrator should release the Missouri State Tax Refund to the debtor because the delinquent debt for the case has been fully satisfied. (Attorney must sign above and type name below) the Court because the delinquent debt for the case has not been fully satisfied. both the debtor and the Court for partial payment as follows: amount to debtor $for Attorney(s) amount to Court $ . Allow 30 days for the Office of State Courts Administrator to process the refund. the debtor because the delinquent debt for the case was reported in error. Allow 30 days for the Office of State Courts Administrator to process the refund. Office and P.O. Address Date Telephone No.: Judge/Clerk Facsimile No.: A copy of the Results of Court Review of Debt Offset Action must be sent to the debtor and to the Office of State Courts E-Mail Address: Administrator. Mobile Tel. No.: OSCA (110-03) GN-110 1 of 1 488.5028 RSMo American LegalNet, Inc. www.USCourtForms.com