Direct Credit Form - State Of Michigan
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1DIRECT CREDIT
Date:
CASE NO. _____
PAYER NAME:
EMPLOYER:
STREET ADDRESS:
STREET ADDRESS:
CITY, STATE, ZIP:
CITY, STATE, ZIP:
(
)
_______
(
)
I
, THE UNDERSIGNED
, DO HEREBY AUTHORIZE THE FRIEND OF THE
COURT TO CREDIT THE ABOVE CAPTIONED ACCOUNT AND SAID CREDIT IS TO BE APPLIED TO THE ARREARS BALANCE.
NO ADDITIONAL DIRECT CREDITS WILL BE APPROVED FOR A MINIMUM OF 12 MONTHS.
EFFECTIVE _____________ I WISH TO WAIVE ANY AND ALL ARREARS OWED DIRECTLY TO MYSELF,
AND THE TOTAL AMOUNT WAIVED IS SUBJECT TO A REVIEW PRIOR TO CREDIT BEING ISSUED.
-OR-
A CREDIT TO BE APPLIED AS FOLLOWS, FOR SUPPORT OWED DIRECTLY TO MYSELF,
AND IS SUBJECT TO A REVIEW PRIOR TO CREDIT BEING ISSUED.
$
CHILD SUPPORT
$
SPOUSAL SUPPORT
$
MEDICAL SUPPORT
$
OTHER
____
TOTAL CREDIT
$
CHILD CARE
$
I AM NOT CURRENTLY RECEIVING CASH ASSISTANCE FROM THE STATE OF MI.
(Payee Initials)
CREDIT WILL NOT BE GRANTED (OR MAY BE REVOKED IF PREVIOUSLY APPROVED) IF PAYMENT WAS TENDERED DURING ANY TIME THE PAYEE WAS
RECEIVING STATE ASSISTANCE WHERE AN ASSIGNMENT OF CHILD SUPPORT RIGHTS WAS GRANTED UNLESS SAID PAYMENTS WERE PROPERLY REPORTED
TO THE DEPARTMENT OF HUMAN SERVICES OR ANY KNOWN OR SUBSEQUENTLY DISCOVERED OBLIGATION TO THE STATE OF MICHIGAN.
SIGNED
DATE ______________
DRIVER LICENSE # AND STATE
________________________________
*ADDRESS
CITY ______________________
STATE ____________________ ZIP CODE__________________________
SOCIAL SECURITY NUMBER
*If address different on system, the address provided will be updated as a legal mailing address.
_____________________________________________
PAYEE PHONE NUMBER
THIS FORM MUST BE NOTARIZED IF NOT SIGNED BEFORE A GENESEE COUNTY FOC EMPLOYEE
SUBSCRIBED AND SWORN TO BEFORE ME THIS ______ DAY OF _______________________A.D., _____________
NOTARY PUBLIC, ________________, MI
COMMISSION EXPIRES:
--------------------------------------------------------------------------------------------------------------------------------------------------------
FOR OFFICE USE ONLY
INFORMATION TAKEN/VERIFIED BY________
Updated 06/2015
CASEWORKER APPROVAL
BENCH WARRANT
YES
NO
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