Form 1900.25 - Texas - Debt Collection Template
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1APPENDIX 7
1900.25 REV-4
App-7 OIG Form 15G
To:
Director, Reports and Control Division, 6AF
From:
___________________________________________
CFO Accounting Center
[Supervisor]
801 Cherry Street, Unit #45, Suite 250
Office: ___________________________________________
Ft. Worth, TX 76102-6882
City, St., Zip ______________________________________
Phone # 817-978-5632
Fax #
817-978-5748
Phone: ___________________________________________
____________________________________________________________________________________________________________
Debtor’s Name (please spell out in full— list aliases on line 10)
1.
____________________________________
________________________________________
_____________________
(Last)
(First)
(Middle)
2.
Address _______________________________________________
____________________________
_____ ________
(if incarcerated give prison address (Street)
(City)
(State)
(Zip)
3.
Employee Identification Number/SSN: ______________________________________________
4.
OIG Case Number:
_______________________________
DOJ Number:
____________________________
5.
Court Docket Number: _______________________
[A
ttach a copy of the Judgment Order (JPC)]
6.
Case Level/Type:
a
Federal
State
Criminal
Civil
x
7.
Probation/Parole Officer/Court Contact: _____________________________________________
Address
_____________________________________________
_____________________________________________
Phone
_____________________________________________
8.
Probation Period:
Start Date
_______________
End Date
________________
Parole
9.
Payment Information: Total Amount Due _____________
Start Date
________________
End Date
___________
Amount Per Payment ___________
Frequency
Annually
Monthly
Other __________
x
10. Additional Information: (e.g., other names debtor has used; business involvements; individuals with joint and severable
responsibility; extenuating circumstances; etc)
11. Appropriation Symbol (if funds are due back to the program): __________________________
Miscellaneous Receipts
[if not available, contact telephone number at top]
12. If funds are due back to the program, Housing Authority or Grantee Name: _________________________________
____
13. Project Number to which the funds should be applied:
[if not available, contact telephone number at top]
14. Program Area:
Housing (Non-FHA)
Public and Indian Housing
Community Planning and Development
Other __________________
Date Form Completed __________________________
A-23
April 2012
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Parent category: Letters