North Carolina Local Government Debt Setoff Clearinghouse Program

1) Name of Local Government:  

2) Date:     3) Type: City/Town   County   Water & Sewer (162A Art. 1)   Joint Regional Agency  (160A Art. 20)

Public Health Authority  (130A Art. 2 - Part 1B)   Metropolitan Sewerage District  (162A Art. 5)   Sanitary District (130A Art. 2 - Part 2)

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.

10) Debt Setoff Contact Name:       11) Phone:   

12) Debt Setoff Contact Email Address:     

13) Debt Setoff Telephone Number for Debtors:  

The Debt Setoff Contact, listed in # 10, and the Telephone Number, listed in # 13 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:

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

  1) Client Software (provided by the NC Local Government Debt Setoff Clearinghouse) via Secure Internet Download 

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

  3) Hardcopy Forms (charges may apply for large volume)

15) Types of Debt: (click all that apply): Property Taxes  Vehicle Taxes Utilities EMS  Health Dept

Inspections Assessments Fines Parking Tickets Traffic Citations Other  List:

16)   I,   17)     ________________________________  (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 

N.C. Local Government Debt Setoff Clearinghouse for Debt Setoff submission.

Agency Approval: __________________________________________   Date: ___________________

                           (Manager/Administrator Signature)

        Instructions for Completion and Submission:

     1) Complete items 1 - 17 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 17 items.

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