2006 Participation Form

1) Name of Local Government:  

2) Date:     3) Type: City/Town   County   Water & Sewer (162A Art. 1)   Joint Regional Agency   

Public Health Authority  Metropolitan Sewage District  Sanitary District

4) Debt Setoff Coordinator Name:       5) Phone:   

6) Address:     7) City/Town/Zip:   

8) Debt Setoff Coordinator Email Address:

9) Other Authorized User Email Address: 

The Debt Setoff Coordinator listed above receives all communications and is authorized to carry out the requirements of the Debt Setoff Act and

any agreements entered herein to enable participation in the North Carolina Local Government Debt Setoff program.

10) Debt Setoff Contact Name:       11) Phone:   

12) Address:  13) City/Town/Zip:    

14) Debt Setoff Contact Email Address:     

15) Debt Setoff Telephone Number for Debtors:

The Debt Setoff Contact, listed in # 10, and the Telephone Number, listed in # 15 above will be provided to debtors via the automated Interactive

Voice Response (IVR) system (877) 843-0330

Software/Data Transfer options between your Local Government Agency and the Clearinghouse:

16) Please select ONE of the following five options (for technical questions call (866) 265-1668)

  1) Client Software (provided by the NC Local Government Debt Setoff Clearinghouse) via Secure Internet Download (technician will call to schedule)

   2) Client Software (provided by the NC Local Government Debt Setoff Clearinghouse) via CD-ROM (for Dial-up users only)

  3) Secure Web Browser Access (for users with own Billing System or Third-Party Billing Company) ASCII format

  4) Secure Web Browser Access (for users with own Billing System or Third-Party Billing Company) Microsoft EXCEL format       

  5) Hardcopy Forms (invoiced by the Clearinghouse for all data entry costs)   

 17)   I,   18)     ________________________________  (authorized official), 

                           (Name)                                                          (Title)                                                            (Signature)

attest that our local agency will follow the written notice and hearing requirements pursuant to GS 105-A-5, prior to transmitting any debts to the 

CLEARINGHOUSE for submission for Debt Setoff.

Agency Approval: __________________________________________   Date: ___________________

                           (Manager/Administrator Signature)

        Instructions for Completion and Submission:

     1) Complete items 1 - 18 above                          2) Click  and to print a hardcopy

     3) Click the Submit button below                     4)  Authorized Official and Manager/Administrator both sign     

     5) A signed original must be mailed: faxing is optional, but suggested, to one of the following: 

  Clicking the Submit button will display a FORM CONFIRMATION with all 18 items.

   Click to transmit this information to the Clearinghouse and complete the process.