Administrative Rules of Montana
Department 23 - JUSTICE
Chapter 23.2 - PROCEDURAL RULES
Subchapter 23.2.4 - Referral of Debt for Recovery and Offset
Rule 23.2.404 - FORMS

Agency Name:

(Department Use Only)

Document Locator No.

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Instructions: Prepare five copies, keeping the last copy for agency file; send remaining four copies to the Department of Administration, Debt Collection Services, Mitchell Building, Helena, MT 59620. A complete file on bad debt must accompany form. See MOM Chapter 2-1100 for necessary instructions.

Agency Document No.

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No Warrant Trans. Doc. No.

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DATA PROCESSING ENCODING SUMMARY

Agency No.

Accounting Entity

Principal Amount Due

Account Name

02

Interest

Penalties

Other Charges

Account Address

Social Security No.

Employer I.D. No.

HISTORY OF COLLECTION

ORIGINAL TRANSACTION

Date

Debt Description

Debt Code

Principal Amount Due

Annual Interest %

Interest

Penalties

Other Charges

Total Amount Due

AGENCY COLLECTION PROCEDURES

Date of First Notice

Check appropriate box:

G Demand for payment was sent to debtor's last known address, but debtor cannot be contacted there;

G Debtor has been offered an appropriate installment payment schedule, but Debtor has declined to agree to the schedule; or

G Although Debtor agreed to an installment schedule, Debtor has not made an installment payment within ten days of the Department's demand letter providing notice of delinquency.

Date of Final Notice

CERTIFICATION AND TRANSFER

I hereby certify this to be a valid debt of the State of Montana and that every means of collection of the Account Receivable identified herein has been utilized according to agency criteria for uncollectibility. This notice will evidence our intent to transfer this debt to the Department of Administration, Debt Collection Services.

Signature of Agency Official Title Date

ACCEPTANCE AND WRITE OFF AUTHORITY

G Approved We hereby accept this debt.

G Not Approved See attached material.

Signature of Agency Official Title Date