Form Am-2 - Offer In Settlement Application Page 2
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1
2OFFER IN SETTLEMENT
Name
Social Security Number
Date of Birth
Address
City/Town
State
Zip Code
Home Phone Number
Work Phone Number
Cell Phone Number
E-mail
To the Deputy Commissioner of the Child Support Enforcement Division (DOR):
1. I submit this Offer in Settlement to settle past-due child support that I owe to the Commonwealth of Massachusetts. DOR’s
records indicate and I believe that the total amount I owe to the Commonwealth is $______________________, as follows:
Arrears Principal
$
Interest
$
Penalty
$
2. I understand that any past-due child support owed to the custodial parent is not subject to or included in this Offer in Settlement and
that even if this Offer in Settlement is approved, DOR will continue its enforcement actions to collect any past-due support owed to
the custodial parent.
3. Submission of this Offer in Settlement does not waive any rights I might have to challenge the amounts stated in paragraph 1 in the
event no settlement is reached.
4. An Offer in Settlement is appropriate because (you may check more than one and attach additional sheets if necessary):
There is serious doubt as to whether I am legally responsible for the past-due support because:
I had no ability to pay the support when it first became due and have no current or likely future ability to pay the past-due
support for the following reasons:
5. I believe the following factors support acceptance of this offer (attach additional sheets if necessary):
6. I have attached a completed Statement of Financial Condition which indicates that I do not have the present financial ability to pay
the past-due support in full.
7. To reach a full and final settlement of this debt, I offer to pay $____________, which is to be paid as follows (check all that apply):
A lump sum payment of $________________ to be paid upon approval of this Offer in Settlement.
Installment payments of $________________ per month for ________ months; the first installment to be paid upon approval
of this Offer in Settlement.
Other ___________________________________________________________________________________________
I certify under the pains and penalties of perjury that the information provided above is true and accurate to the best of my knowledge
and belief. I understand that if I fail to provide complete information or provide false information, my Offer in Settlement will be
denied. I also understand that DOR may continue its enforcement actions while this Offer in Settlement is under consideration.
Signature
Date
AM-2 2/23/10
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