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					                                                                                                                                                                                                                                                                                                     9/7/2011


Request for Accounts Receivable to be Written Off
Date Referred to the Bureau of Finance & Accounting:

                                                                                                                                                                                                                                          Other Details (Give the status of
                                                                                                                                                                                                                                                                               Due Diligence (Indicate how
                                                                                                                                                                                                                                           the account and any additional
                                                                                                                                                                                       Total Due to Agency                                                                     the Agency has satisfied the
                                                                                                                                                                                                                                          information to support why the
                                                            Responsible Party Last Name /               Debtor Account                                     Fees, Fines, Penalties,   (This amount should be                Original Due                                       Due Diligence Requirement for
Program Area     System      Responsible Party First Name                                   Co-Debtor                    Invoice #   Original Amount Due                                                       Debt Type                    debt has not been collected.
                                                                  Company Name                             Number                                                   etc.              the total amount to be                   Date                                           the debt per Chap. 691-21-003
                                                                                                                                                                                                                                             Indicate if the Debtor is in
                                                                                                                                                                                            Written Off)                                                                       F.A.C. (e.g., # of letters sent,
                                                                                                                                                                                                                                          Bankruptcy or has passed away,
                                                                                                                                                                                                                                                                                             etc.)
                                                                                                                                                                                                                                                         etc.)

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                                                                                                                                              1
                                                                                                                                                                                                                                                                                                  9/7/2011


                                                                                                                                                                                                                                       Other Details (Give the status of
                                                                                                                                                                                                                                                                            Due Diligence (Indicate how
                                                                                                                                                                                                                                        the account and any additional
                                                                                                                                                                                    Total Due to Agency                                                                     the Agency has satisfied the
                                                                                                                                                                                                                                       information to support why the
                                                       Responsible Party Last Name /               Debtor Account                                       Fees, Fines, Penalties,   (This amount should be                Original Due                                       Due Diligence Requirement for
Program Area   System   Responsible Party First Name                                   Co-Debtor                    Invoice #    Original Amount Due                                                        Debt Type                    debt has not been collected.
                                                             Company Name                             Number                                                     etc.              the total amount to be                   Date                                           the debt per Chap. 691-21-003
                                                                                                                                                                                                                                          Indicate if the Debtor is in
                                                                                                                                                                                         Written Off)                                                                       F.A.C. (e.g., # of letters sent,
                                                                                                                                                                                                                                       Bankruptcy or has passed away,
                                                                                                                                                                                                                                                                                          etc.)
                                                                                                                                                                                                                                                      etc.)

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                                                                                                                        TOTALS                   0.00                      0.00                     0.00




                                                                                                                                          2
                           DEBT TYPES

CODE                               DESCRIPTION
  1    Cost of Care
  2    Court Ordered (Claims)
  3    Criminal History Requests
  4    Damage of State Property (Accident Claims)
  5    Driver License Fees
  6    Emergency Response Reimbursement
  7    Fees, Fines & Forfeitors
  8    Healthcare Facility Assessment
  9    HMS Clients
 10    Legality Expenses
 11    Lottery Ticket Sales
 12    Motor Vehicle Registration, Title and Vessel Fees
 13    Non-Compliance Penalties
 14    Nonpayment for State Goods/Services (Foster Care, Etc.)
 15    Other
 16    Overpayment of State Funds (Salary & Leave Overpayments, etc.)
 17    Public Assistance Benefits
 18    Restitution
 19    Returned Checks
 20    Taxes
 21    Tuition Reimbursement
 22    Unemployment Compensation Benefit Overpayments




FORM DFS-A1-1829. Effective 3/08
ALABAMA          AL
ALASKA           AK
ARIZONA          AZ
ARKANSAS         AR
CALIFORNIA       CA
COLORADO         CO
CONNECTICUT      CT
DELAWARE         DE
DISTRICT OF      DC
COLUMBIA
FLORIDA          FL
GEORGIA          GA
HAWAII           HI
IDAHO            ID
ILLINOIS          IL
INDIANA          IN
IOWA             IA
KANSAS           KS
KENTUCKY         KY
LOUISIANA        LA
MAINE            ME
MARYLAND         MD
MASSACHUSETTS    MA
MICHIGAN         MI
MINNESOTA        MN
MISSISSIPPI      MS
MISSOURI         MO
MONTANA          MT
NEBRASKA         NE
NEVADA           NV
NEW HAMPSHIRE    NH
NEW JERSEY       NJ
NEW MEXICO       NM
NEW YORK         NY
NORTH CAROLINA   NC
NORTH DAKOTA     ND
OHIO             OH
OKLAHOMA         OK
OREGON           OR
PENNSYLVANIA     PA
RHODE ISLAND     RI
SOUTH CAROLINA   SC
SOUTH DAKOTA     SD
TENNESSEE        TN
TEXAS           TX
UTAH            UT
VERMONT         VT
VIRGINIA        VA
WASHINGTON      WA
WEST VIRGINIA   WV
WISCONSIN       WI
WYOMING         WY
                                SYSTEM

SHORT TITLE                             DESCRIPTION
    BC        Bad Check
    LAB       LAB Spreadsheet
    LCT       Legal Case Tracking
     LE       Division of Law Enforcement
   MISC       Miscellaneous
   PWS        Potable Water Systems (Drinking Water)
   STCM       Storage Tank Contamination and Monitoring System
  SUPRS       Submerged & Uplands Public Revenue System
   WAFR       Wastewater Facility Regulation
  Wakulla     Wakulla Springs Lodge
                           PROGRAM AREA

 SHORT TITLE                              DESCRIPTION
Air            Division of Air Resources Management
Beaches        Bureau of Beaches and Coastal Systems
BER            Bureau of Emergency Response
CAMA           Coastal and Aquatic Managed Areas
CFD            Central Florida District
Drycleaner     Drycleaner Program (STCM)
LAB            Bureau of Laboratory Services
LCT            Legal Case Tracking
NED            Northeast District
NWD            Northwest District
NWD1           Northwest District 1
NWD2           Northwest District 2
OGT            Office of Greenways and Trails
Parks          Division of Recreation and Parks
SED            Southeast District
SED1           Southeast District 1
SFD            South Florida District
State Lands    Division of State Lands
STCM           Storage Tank Contamination Monitoring
SWD            Southwest District
Waste          Division of Waste Management
Water          Division of Water Resources Management

				
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