THE PEOPLE OF

 The State of Michigan

 
 

Prisoner’s name

v

Prisoner no.

SID

DOB

Institution name and address

On 

Date 

 this court entered an order to remit prisoner funds for payment toward

an obligation ordered in a judgment of sentence or other order.

That financial obligation has been paid in full to the court as of 

Date

 . 

 

                     

Court clerk/Deputy court clerk signature and date

CERTIFICATE OF MAILING

I served a copy of this satisfaction of financial obligation on the prisoner 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.

Date

 

Signature  

 

 

 

 

 

 

 

 

 

 

 

 
  
 
 
 
 
 

 
 

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

         MDOC-CourtOrders@michigan.gov
     └                                                                           ┘

Approved, SCAO
Form MC 290, Rev. 5/21
Page 1 of 1

Distribute form to: 
Court 
MDOC Court Order Unit
Prisoner

STATE OF MICHIGANJUDICIAL DISTRICTJUDICIAL CIRCUITSATISFACTION OF FINANCIAL OBLIGATIONCASE NO. and JUDGECourt addressCourt telephone no.