NC Local Government Debt Setoff Clearinghouse Program
1) Name of Local Government:
2) Date: 3) Person Requesting Change(s):
** Complete only items that have changed **
DEBT SETOFF COORDINATOR Section:
4) Debt Setoff Coordinator Name: 5) Phone:
6) Address: 7) City/Town/Zip:
8) Debt Setoff Coordinator Email Address:
9) Other Authorized Users Email Addresses:
Email Addresses (cont.):
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.
DEBT SETOFF CONTACT Section:
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 check ONE of the following four 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) Secure Web Browser Access (for users with own Billing System or Third-Party Billing Company) ASCII format
3) Secure Web Browser Access (for users with own Billing System or Third-Party Billing Company) Microsoft EXCEL format
4) Hardcopy Forms (invoiced by the Clearinghouse for all data entry costs)
Instructions for Completion and Submission:
1) Complete items 1 - 16 above 2) Click and to print a hardcopy
3) Click the Submit button below
Clicking the Submit button will display a FORM CONFIRMATION with all 16 items.
Click to transmit this information to the Clearinghouse and complete the process.