Mont. Admin. r. 23.2.404

Current through Register Vol. 24, December 20, 2024

Rule 23.2.404 - FORMS

(1) The department shall refer a debt to the department of administration, or other agency designated by law, on the attached form.

BAD DEBT CERTIFICATION & TRANSFER FORM

Agency Name:	(Department Use Only)
	Document Locator No.	<
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.	<
	No Warrant Trans. Doc. No.	<

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

Mont. Admin. r. 23.2.404

NEW, 1999 MAR p. 984, Eff. 5/7/99.

2-4-201, MCA; IMP, 17-4-110, MCA;