Form Arc150 - Revenue Recapture Act Certification And Decertification And Modification Request
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1ARC150
Revenue Recapture Act Certification
and Decertification and Modification Request
Individual(s) being certified
First name
Initial
Last name
Social Security number
Spouse’s first name (if filing a joint claim)
Initial
Last name
Social Security number
Last known address
City
State
Zip code
Date of birth
Spouse’s date of birth (if filing a joint claim)
Certifying agency
Agency name
Minnesota tax ID number
Address
City
State
Zip code
Agency contact person
Daytime phone number
(
)
Liability
Amount of liability
Date of debt
Agency account number
Is liability for criminal restitution?
Yes
No
Decertification or modification request
(leave blank if you are not cancelling or updating an existing claim)
Check one box only (if applicable):
If you are updating an existing claim:
To cancel the claim
To update the claim
Enter change to claim (+ or –):
New balance of claim:
Mail completed form to: Minnesota Revenue, Collection Division, 600 North Robert St., St. Paul, MN 55146
or fax to: 651-556-5120. Be sure to keep a copy for your records.
Instructions
Agency name
Liability
Claims are in effect until paid or
canceled.
You must provide the state agency or county
The debt must be a minimum of $25 and
name. Do not use a generic name such as
may include criminal fines.
The agency must notify the department
“Accounting” or “Child Support Collec-
within 30 days after the debt has been satis-
Agency account number (optional)
tions” without identifying the agency to
fied or reduced by at least $200.
Please assign each account a 1- to 9-digit
which the office belongs.
numeric number.
To cancel or update claims filed, com-
Minnesota ID number for revenue
plete the “Decertification or modification
The account number is an optional field
recapture purposes
request” area on a copy of the original claim
for use in recording a case number or other
Before you can participate in the recapture
filed with the department.
type of identifying number that an agency
program, the agency must have an as-
Questions?
may have assigned to a debt.
signed Minnesota tax ID number that is
If you have questions regarding the revenue
authorized for recapture purposes only. Call
This number will appear on reports of
recapture program, you can call the depart-
651-556-3037 to apply for one.
setoffs.
ment at 651-556-3037 or fax your questions
to 651-556-5120.
Rev. 8/08
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