Free Notice of Intent to Intercept State Income Tax - Michigan

Approved, SCAO

Original - Payer Copy - Court

STATE OF MICHIGAN
JUDICIAL CIRCUIT - FAMILY DIVISION

COUNTY
Court address

NOTICE OF INTENT TO INTERCEPT STATE INCOME TAX

CASE NO. PETITION NO.

Telephone no.

1. In the matter of
(name(s), alias(es), DOB)

TO:

Date of notice Social security number Amount delinquent

1. Any Michigan tax refund due to you may be intercepted for the amount shown above. Your name is being referred to the Michigan Department of Treasury for collection of past due reimbursement for the cost of care and/or service. 2. You have the right to an informal hearing if you believe the amount claimed above is in error. To request an informal hearing, you must contact the circuit court at the address shown above within 7 days of the date of this notice or another date specified by the court. 3. Notice to intercept a joint refund will be sent to you automatically by the Michigan Department of Treasury at the time your return is processed.

Do not write below this line - For court use only

JC 60 (6/03)

NOTICE OF INTENT TO INTERCEPT STATE INCOME TAX

MCL 712A.18(2), MCL 769.1(7)