In the matter of 

First and last name(s), alias(es)

THE COURT FINDS:

1. On 

Date

 this court entered an order directing

First, middle initial, and last name                           • Social security no.

First, middle initial, and last name                       • Social security no.

     • 

 

 

Address

City, state, zip

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

2. The above person(s) has/have failed to comply with the order of reimbursement and is/are delinquent.

 is $ 
 

 . The account is delinquent $ 

 .

 

3. A notice of intent to intercept state income tax was sent to 

Name(s)

 on

 .

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

 

 of any state income 

Address

City, state, zip

• 

 

 

 

   

 

 • 

 • 

 • 

 • 

Date

Date

County/Court name

Department/Address

Address

City, state                                                   • Zip                    • Telephone no.

CERTIFICATE OF MAILING
I served a copy of this order on the person(s) named above by first-class mail addressed to their last-known addresses 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.

Judge signature and date

Date

 

Signature  

 

 

STATE OF MICHIGANJUDICIAL CIRCUIT - FAMILY DIVISIONCOUNTYORDER TO INTERCEPTSTATE INCOME TAX• CASE NO.   PETITION NO.   JUDGECourt address                                        • Zip codeCourt telephone no.Approved, SCAOForm JC 61, Rev. 3/23MCL 712A.18(2), MCL 769.1(7)Page 1 of 1Distribute form to: CourtDebtorDepartment of Treasury