DHS-307, Request for Central Receipt Adjustment/Suspense ...
|REQUEST FOR CENTRAL RECEIPT ADJUSTMENT/SUSPENSE WORK |
|Michigan Department of Health and Human Services |
|Michigan State Disbursement Unit |
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|Note: This request form may only be used for ONE issue/resolution for a Receipt Adjustment or ONE Suspense Code. Incomplete request forms will be rejected. |
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|Date of Request |Date of Resubmission |
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|(If request has been resubmitted, please do not remove comments in the REQUEST STATUS field.) |
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|Requester Name |
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|County Name and County Code |Organizational Affiliation |
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|Phone Number |Email Address |
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|ACTION REQUESTED |
| Single County Suspense Request (Fast-Track) |
|(If box is checked, the county confirms that this non-custodial parent (NCP) is not an NCP on any case in any other county [including multiple member IDs] and the |
|county assumes total liability for errors that may result from this requested action.) |
| Identify (Section A) | Refund to Other Party (Section D) |
| Reapply (Section B) | Reissue Check Same Recipient (Section E) |
| Allocate/Distribute (Section C) | Reissue Check Different Recipient (Section F) |
| Release SJTO (Injured spouse form is on file) | Stop-Pay (Section G) |
| Refund to Payer | |
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|REASON FOR ACTION |
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|ADDITIONAL INFORMATION |
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| Make Whole Request |
|Where did the error originate? |
| CEU | CFU | FOC | MiCSES | MiSDU |
| PA | Other | Requesting Entry | SIU | |
|Nature of the error |Status of the receipt? |
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|Original Receipt Case Information |
|Suspense Code(s) (If necessary) |NCP Member ID |
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|Number of Receipts |NCP Name |
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|Receipt Number(s)/Amounts |
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|Total Amount |$ |
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|SECTION A - Identify |
|Receipt Number(s) |NCP Name |
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|NCP Member ID |Docket Number |
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|SECTION B - Reapply |
|NCP Member ID |NCP Name |
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|IV-D Case Number |Docket Number |
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|Amount of Reapply |$ |Original Receipt Amount |$ |
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|SECTION C – Allocate/Distribute |
|Total Receipt Amount |$ |
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|Docket Number |IV-D Case Number |Obligation |Arrearage Type |Amount |
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|If applied amounts do not equal the total receipt, state the reason and disposition of the remainder of the receipt. |
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|SECTION D – Refund to Other Party |
|OTHP Number |Reason for Refund |Other Party Name |
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|Information to be entered on check memo line (limit 50 characters) |
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|If refund amount is not equal to receipt amount, enter reason here |
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|SECTION E – Reissue Check Same Recipient |
|Check Number |Amount |
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|Recipient Name |Recipient ID Number |
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|Reason for Reissue |
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|SECTION F – Reissue Check Different Recipient |
|Check Number |Amount |
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|Recipient Name |Recipient ID Number |
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|Other Party Recipient Name |Other Party Recipient ID Number |
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|Reason for Reissue |
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|SECTION G – Stop-Pay |
|Check Number |Amount |
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|Recipient Name |Recipient ID Number |
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|Reason for Stop-Pay |
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|The Michigan Department of Health and Human Services will not exclude from participation in, deny benefits of, or discriminate against any individual or group because |
|of race, sex, religion, age, national origin, color, height, weight, marital status, gender identification or expression, sexual orientation, partisan considerations, |
|or a disability or genetic information that is unrelated to the person’s eligibility. |
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