STATE OF MICHIGAN

JUDICIAL CIRCUIT
COUNTY

NOTICE TO WITHHOLD INCOME
FOR FEES AND COSTS
 
 Original 

 Modified

CASE NO. and JUDGE

 

 

 

 

 

 

Telephone no.

Friend of the court address              
 

   

 

 

 

Payer’s name and address 

Source of income name and address 
PAYROLL DEPARTMENT: CONFIDENTIAL

Payer’s social security number

From money otherwise paid to the payer, withhold 
the  following  amount  and  send  it  to  the  address 
listed in item 2: 
$ 
 
sanctions. This withholding is not for child or spousal
support  and  is  in  addition  to  any  withholdings 
ordered for support.

 for fees, fines, costs and

1. An order to withhold the payer’s income for fees, fines, costs, and sanctions in this case has been entered.
2. DO NOT SEND THESE PAYMENTS TO THE MICHIGAN STATE DISBURSEMENT UNIT (MiSDU). Remit payments to 
 

  at the following address:

 Friend of the court 

 Circuit court clerk 

the 

 

 

 

in full.

3. If you cannot remit the entire amount from one paycheck, withhold up to the limits in item 7 until the entire amount is paid 
 
4. Withholdings for child, medical, or spousal support sent to MiSDU, or for health-insurance premiums take precedence 
  over this notice.
5. You must start withholding within 7 days after receiving this notice. This notice expires after you have sent the entire 
  amount identified above. You may be held in contempt and have to pay fines plus the amounts you should have withheld 
  and any other penalties set by state law if you knowingly and intentionally fail to comply with this notice.
6. Any money you withhold reduces the amount you would otherwise have to pay the payer.
7. If there is more than one withholding against a payer, you must withhold for all of them, up to certain limits. Withholding 
 
for this notice cannot reduce the payer’s income by more than 25 percent under the Federal Consumer Protection Act, 
  15 USC 1673(a). If the state of the payer’s principal place of employment requires a smaller amount, withhold only to 
 
that limit. You may contact the friend of the court office identified above for assistance in withholding and sending the 
  correct amount.
8. If you are concerned about the validity of this notice, contact the friend of the court office identified above.
9. You can combine withheld amounts for more than one payer in a single payment. You must identify the amount withheld 
 
10.  It is illegal to refuse to employ, discharge, take disciplinary action against, or impose a penalty against a payer because 
  of this withholding. If you do, you may be required to make full restitution, including reinstatement and back pay. You 
 
 
  cannot charge a fee to the payer for withholding income pursuant to this notice.
11.  You must notify the friend of the court office if you no longer pay the payer income before this notice has been paid in 
  full, and provide the payer’s last-known address and the name and address of the payer’s new employer, if known.
 

for each payer and the payer’s social security number, case number, and date withheld.

CERTIFICATE OF MAILING
I  served  a  copy  of  this  notice  on  the  source  of  income  and  the  payer  by  first-class  mail  addressed  to  their  last-known 
addresses  as  defined  in  MCR  3.203.  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.

Date

 

Approved, SCAO
Form FOC 119, Rev. 6/22
MCL 552.509, MCL 552.609, MCL 552.611, MCL 552.611a, MCL 552.612, 
MCL 552.613, MCL 552.614, MCL 552.623
Page 1 of 1

Signature  

 

 

Distribute form to: 
Source of income
Friend of the court
Payer

To the Clerk:  For FOC office