Form Am-2 - Offer In Settlement Application
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1
2OFFER IN SETTLEMENT
Name:
Commonwealth of Massachusetts
Department of Revenue
SSN:
APPLICATION
Child Support Enforcement Division
Case No:
IMPORTANT! DOR is authorized to settle arrears owed to the Commonwealth only.
DOR cannot settle arrears owed to a custodial parent.
Check List of Required Items
The following documentation must be submitted with your application or your application will be returned as
incomplete. Indicate if any of the items are not applicable by writing N/A. DOR may require you to provide
additional documentation as the evaluation of your offer in settlement proceeds.
Unless DOR has specifically asked for the original of a document, please submit copies only. DOR will not return
any documents to you.
Completed Application (this two-page form).
Completed Statement of Financial Condition.
Verification of Income
Complete pay stubs for the past 3 months or financial statements for the past 2 years if you are self-employed.
Information from the Social Security Administration (SSA).
Social Security Earnings Statement (required for all applicants). Go to
for instructions on requesting
an Earnings Statement. If you receive Supplemental Security Income (SSI) or Social Security Disability Insurance
(SSDI), attach a copy of the award letter.
Bank Information
Complete bank statements for all checking, savings and other bank accounts for the past 3 months.
Medical Records
Copies of any doctors’ letters, reports or medical records that support any claim of medical disability.
Power of Attorney
Power of Attorney if this offer is submitted by a designated representative.
Authorization to Request Consumer Credit Report
I, ____________________, hereby authorize DOR to obtain, and all consumer credit reporting agencies to furnish,
my full credit report in accordance with §§ 1681b(a)(2), (4) and (5), 1681b(f), 1681e and any other applicable
sections of the Fair Credit Reporting Act (FCRA). (15 USC § 1681 et. seq.). I agree that DOR’s use of my credit
report for collection and enforcement of my child support order is a permissible purpose as that term is defined in §
1681b of the FCRA.
This authorization does not expire and any revocation of this authorization must be made in
writing to DOR. Copies of this authorization are as good as the original.
____________________________________________
____________________________
Signature
Date
Mail your completed and signed application, with copies of all required documents, to:
Department of Revenue
Child Support Enforcement Division
Attn:
AM-2 2/23/10
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