Prisoner’s name

v

Prisoner no.

SID

DOB

Institution name and address

1. The prisoner owes a balance of $ 
 , not including restitution, which is collected by the Department
  of Corrections in accordance with MCL 791.220h, for the obligation ordered in the judgment of sentence or other order   

 

 . (A copy of the judgment of sentence or order is attached.)

2. For payment toward the obligation, the Department of Corrections shall collect 50 percent of all funds received by the 
  prisoner over $50.00 each month.

3. If the amount withheld at any one time is $100.00 or less, the Department of Corrections shall continue collecting  
funds from the prisoner’s trust account until the sum of the amounts collected exceeds $100.00, at which time the  
 
  Department of Corrections shall remit that amount to this court to 

 the above address. 

 the following address:

 

 

 
 

4. Withdrawal from the prisoner’s trust account and remittance to this court shall continue until the obligation is paid in full.
 
If the prisoner transfers to a facility at which a prisoner’s trust account is not maintained, or if the prisoner is paroled, 
  discharged, or dies, any withheld funds shall be remitted to this court.

 

                     

 

                     

Judge signature and date

THE PEOPLE OF

 The State of Michigan

 
 

THE COURT FINDS:

IT IS ORDERED:

dated 

 

   

STATE OF MICHIGANJUDICIAL DISTRICTJUDICIAL CIRCUITCOUNTY ORDER TO REMIT PRISONER FUNDS FOR FINES, COSTS, AND ASSESSMENTSCASE NO. and JUDGECourt addressCourt telephone no.Approved, SCAOForm MC 288, Rev. 12/22MCL 769.1IPage 1 of 2Distribute form to:CourtMDOC Court Order UnitPrisonerOrder to Remit Prisoner Funds for Fines, Costs, and Assessments 
Page 2 of 2

(12/22) 

Case No. 
 

CERTIFICATE OF MAILING

I certify that on this date I served a copy of this order on the prisoner 

 at sentencing by personal service.
 at the institution/facility by first-class mail addressed to its last-known address as defined by MCR 2.107(C)(3).

I declare under the penalties of perjury that this certificate of mailing has been examined by me and that its contents are 
true to the best of my information, knowledge, and belief.

 

Signature  

 

 

Date

 
  
 
 
 
 
 

 
 

          Send a copy of this order by first-class mail or email to:
          ┌                                                                           ┐
                ATTN: Court Order Unit
                Michigan Department of Corrections
                206 E. Michigan Ave.
                PO Box 30003
                Lansing, MI 48909

                MDOC-CourtOrders@michigan.gov
          └                                                                           ┘