Ar Write Off Request Form
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2AR WRITE-OFF REQUEST FORM
FROM
Name (please print)
PLEASE MAIL TO:
Department
GAB NTR Unit
Office of the Comptroller
Position
One Ashburton Place, 9th Floor
Boston, Massachusetts 02108
Phone
Please identify totals in this request: Number of RE lines for WO #________, Total Amount of all lines $_______________
RE __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ ___________________
Dept
20 Character Document Number
Line# $ Amount to Write Off
WO__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ ___________________
Dept
20 Character Document Number
Line# $ WO Line amount
RE __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ ___________________
Dept
20 Character Document Number
Line# $ Amount to Write Off
WO__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ ___________________
Dept
20 Character Document Number
Line# $ WO Line amount
Please check here if page 2 (or other addendum) is used to record additional WO/RE documents
General Description of Receivables:
Has Receivable(s) been placed for collection: YES: _____NO: _____
Intercept: YES: _____NO: _____
Collection Agency Name: _____________________________________________________________________________
Reason for Collection Agency Return: ___________________________________________________________________
(Attach notification from Collection Agency returning outstanding debt).
Reason Receivable has not been placed for collection or intercept:____________________________________________
_________________________________________________________________________________________________
Reason for write-off:
Note: This document must have attached: A signed cover letter requesting write-off, a screen print from MMARS of the
WO document in Pending Status, and any supporting documentation i.e. Probate Records, agreements/correspondences.
All preconditions for Write-Off as stated in 815 CMR 9:00 Debt Collection, have been met.
Authorized MMARS Signature:
Date:
/
/
Name (printed):
Title:
For any questions, please contact:
OSC-GANon-TaxRevenueUnit@MassMail.State.MA.US
.
Internal Use Only
Date Complete Documents Received _____/_____/_____
Date Approval in MMARS Submitted _____/_____/_____
Manager Approval Signature_________________________________________
Date _____/_____/_____
Director Approval Signature _________________________________________
Date _____/_____/_____
Deputy Approval
Signature, if required
________________________________
Date _____/_____/_____
AR Write-Off Request Form – ver2.3 rev. 04.20.16
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Parent category: Financial