Approved, SCAO
Original - Court 1st copy - Debtor 2nd copy - Department of Treasury
STATE OF MICHIGAN
JUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY
Court address
ORDER TO CANCEL STATE INCOME TAX INTERCEPT
CASE NO. PETITION NO.
Court telephone no.
1. In the matter of
(name(s), alias(es))
THE COURT FINDS: 2. On
Date
this court entered an order directing the Michigan Department of Treasury to withhold up to of any state income tax refund due to
$
First, middle initial, and last name and social security no. Address City, state, zip
First, middle initial, and last name and social security no. Address City, state, zip
to reimburse the court for costs of care and/or services assessed in the above matter which had become delinquent. in full $ 3. The above person(s) paid in part $ 4. Other: on
Date
on
Date
. .
5. IT IS ORDERED the order to intercept state income tax is cancelled and the Michigan Department of Treasury shall delete the order from its records.
Date
Judge
Bar no.
CERTIFICATE OF MAILING I certify that on this date copies of this order were served upon the person(s) named above by ordinary mail at their last known addresses.
Date
Signature
Do not write below this line - For court use only
JC 62 (6/03)
ORDER TO CANCEL STATE INCOME TAX INTERCEPT
MCL 712A.18(2), MCL 769.1(7)