Free Order to Intercept State Income Tax - Michigan

Approved, SCAO

STATE OF MICHIGAN
JUDICIAL CIRCUIT - FAMILY DIVISION

COUNTY
Court address

ORDER TO INTERCEPT STATE INCOME TAX

· CASE NO. NO. PETITION
Zip code

Original - Court 1st copy - Debtor 2nd copy - Department of Treasury

·

Court telephone no.

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

THE COURT FINDS: 2. On
Date

this court entered an order directing

·

First, middle initial, and last name Address City, state, zip

·

Social security no.

·

First, middle initial, and last name Address City, state, zip

·

Social security no.

to reimburse the court for costs of care and/or services assessed in the above matter. The balance owing as of is $
Date

. The account is delinquent $

.

3. The above person(s) has/have failed to comply with the order of reimbursement and is/are delinquent. 4. A notice of intent to intercept state income tax was sent to
Name(s)

on

. IT IS ORDERED the Michigan · 5. refund due the above person(s)Department of Treasury shall withhold up to $ and shall forward the withholdings to:
Date

of any state income tax

· · · ·

County/Court name Department/Address Address City, state

·

Zip

·

Telephone no.

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 61 (6/03)

ORDER TO INTERCEPT STATE INCOME TAX

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