FIA-820, Support Collection Payment Request by iht11609

VIEWS: 20 PAGES: 1

									   SUPPORT COLLECTION PAYMENT REQUEST                                                    1. FOR CENTRAL OFFICE USE ONLY
             Michigan Family Independence Agency
Request Refunds Separately by Collection Type.
                                                                                         2. Load Number           3. Prog       4. County Number
Do Not Make Entries in Shaded Areas PLEASE TYPE OR PRINT CLEARLY
5. Client’s Name (Last, First, Middle)                                                                       6. FIA Case Number

7. Payment Amount                           8. Collection Period – Beginning Month and Year                  9. Number of Pay Periods
                                                                         0     1
10.                                         10A. Payee Name

       Pay to Friend of the Court
                                            10B. Street Address
       Pay to Client
                                            10C. City                                                                           10D. State             10E. Zip Code
       Pay to Taxpayer
11. FOC 12. FIPS Number                     13. Court Case Number                                      14. Payer Name


REFUND INFORMATION
15. Refund Reason (Check Box that Identifies Primary Reason for Refund Request)
       TANF Closed-Decert Eff.                        FIA Overpaid                   Case Number Error                NSF                           Other - Specify
       Person Off TANF-Decert. Eff.                   Account Overpaid               Collection Type Error            Offset in Error
16.                                                                  17.              18A.             19.              20. Amount of        21.               22.
                                                                       Reported        Collection        Collection         Refund                               Amount
                     Type of Collection                               To MiCSES          Mo./Yr.           Amount         Requested          Adjustment         Approved
16A. Child Support
       Current              -27         Federal Offset        -25            YES
       Regular Arrears      -27         State Offset          -24            NO                        $                $                                      $
       Current              -27         Federal Offset        -25            YES
       Regular Arrears      -27         State Offset          -24            NO                        $                $                                      $
       Current              -27         Federal Offset        -25            YES
       Regular Arrears      -27         State Offset          -24            NO                        $                $                                      $
       Current              -27         Federal Offset        -25            YES
       Regular Arrears      -27         State Offset          -24            NO                        $                $                                      $
       Current              -27         Federal Offset        -25            YES
       Regular Arrears      -27         State Offset          -24            NO                        $                $                                      $
16B. Other Collections                                               16B. Collection Period or Date
       Medical             IV-E Court or State Ward       Specify:
       Blood Test          State Ward Charge Back                                                      $                $                                      $
       Medical             IV-E Court or State Ward       Specify:
       Blood Test          State Ward Charge Back                                                      $                $                                      $
       Medical             IV-E Court or State Ward       Specify:
       Blood Test          State Ward Charge Back                                                      $                $                                      $
23. Totals                                                                                                              23A.                 23B.              23C.
                                                                                                                        $                                      $
REBATE/REIMBURSEMENT INFORMATION
24. Reported           25. Reported          26. Correct             27. Correct      28.                               29. Amount           30.               31.
   Collection             Collection            Collection              Collection               Payment                  of Payment                             Amount
     Mo./Yr.               Amount                Mo./Yr.                 Amount                    Type                     Request          Adjustment         Approved
                                                                                            Rebate – 26
                       $                                             $                      Reimbursement – 28          $                                      $
                                                                                            Rebate – 26
                       $                                             $                      Reimbursement – 28          $                                      $
32. Totals                                                                                                              32A.                 32B.              32C.
                                                                                                                        $                                      $
33. Additional Explanation



34. Authorized Signature                                    35. Agency                36. County                        37. Phone Number            38. Date
                                                               FOC             OCS

AUTHORITY:       45 CFR 302.32 AND 302.51.         The Family Independence Agency will not discriminate against any individual or group because of race,
                                                   sex, religion, age, national origin, color, height, weight, marital status, political beliefs or disability. If you
PENALTY:         State will retain funds in error. need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to
COMPLETION: Required:                              make your needs known to an FIA office in your county.
FIA-820 (Rev. 9-04) Previous edition may be used. MS Word
AT 2004-034, Attachment 1

								
To top