Michigan > Local County > Genesee
Direct Credit Form - Michigan
| Direct Credit Form Form. This is a Michigan form and can be used in Genesee Local County . |
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DATE: _________________ DIRECT CREDIT CASE NUMBER: _________ ______________________ _________ CASEWORKER: __________________________________________ PAYER NAME: ___________________________________ S.S. # ______________________________________________ I, THE UNDERSIGNED __________________________________________________, DO HEREBY AUTHORIZE THE (PAYEE NAME) FRIEND OF THE COURT TO CREDIT THE ABOVE CAPTIONED ACCOUNT EFFECTIVE _____________________________: I WISH TO WAIVE ANY AND ALL ARREARS OWED DIRECTLY TO MYSELF WHICH IS CURRENTLY $ ______________________________, AND IS SUBJECT TO A REVIEW PRIOR TO CREDIT BEING ISSUED. A CREDIT TO BE APPLIED AS FOLLOWS, FOR SUPPORT OWED DIRECTLY TO MYSELF, AND IS SUBJECT TO A A REVIEW PRIOR TO CREDIT BEING ISSUED. $_____________________________ CHILD SUPPORT $ _____________________________ MEDICAL SUPPORT $ _____________________________ CHILD CARE $_____________________________ SPOUSAL SUPPORT $ _____________________________ OTHER _________________ $__________________________ TOTAL CREDIT I AM NOT CURRENTLY RECEIVING STATE ASSISTANCE. ______________________. (PAYEE INITIALS) CREDIT WILL NOT BE GRANTED, OR REVOKED, IF PREVIOUSLY GRANTED, 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 HAD BEEN PROPERLY REPORTED TO THE DEPARTMENT OF HUMAN SERVICES AGENCY, OR ANY KNOWN OR SUBSEQUENTLY DISCOVERED OBLIGATION TO THE STATE OF MI. CREDIT WILL NOT BE AUTHORIZED FOR ANY ADVANCE PAYMENTS. ________________________________________ DRIVER LICENSE NUMBER AND STATE SIGNED ________________________________________ ADDRESS ______________________________________ THIS FORM MUST BE NOTARIZED IF NOT SIGNED BEFORE A CASEWORKER OR PARALEGAL ______________________________________ ______________________________________ S.S. # ___________/______________/____________ SUBSCRIBED AND SWORN TO BEFORE ME THIS ______ DAY OF _____________________________ A.D., ___________ _______________________________________ NOTARY PUBLIC COMMISSION EXPIRES: ________________ INFORMATION TAKEN/VERIFIED BY: ___________________ ___________________________________ _ ___________________________________ FOR OFFICE USE ONLY IDENTIFICATION VERIFIED OR CASEWORKERS INITIALS SUPERVISOR APPROVAL NOTARIZED NOTICE SENT TO PAYER STATING THAT NO ADDITIONAL DIRECT CREDITS WILL BE AUTHORIZED. BENCH WARRANT Direct credit 3/98 REV 05-06 American LegalNet, Inc. www.FormsWorkflow.com YES NO
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