2010 Participation Form

(Allows for debts from august 2009 - December 2010)

Required Information
1) Date: 2) Local Government Name:
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) Coordinator Name: 5) Coordinator Phone:
6) Coordinator Email Address:
7)Other Authorized Users Email Addresses:
8)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.

9) Contact Name: 10) Contact Phone:
11) Contact Email Address:
12) Debt Setoff Telephone Number for Debtors: 13) Fax Number for Refund Requests:

The Local Government Name (#2), Debt Setoff Contact (#9), and the Contact Telephone Number (#12) 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 Debt Setoff Clearinghouse:
14) Please select ONE of the following three options:
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)
3) Hardcopy Forms (charges may apply for 50 or more debts)

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, (Printed Name)

17)    (Title),


18)   ___________________________________________________________________________________________________ (Authorized official 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.


19)   _______________________________________________________________________  (Local Govt. Manager/Administrator signature)  Date: ____________________



Instructions for Completion and Submission:
1) Complete items 1 -19 above; 2) Print this form; 3) Click Submit; 4) Authorized Official and Local Government Manager/Administrator must sign
5) Signed original must be mailed (not faxed) to ONE of the following:

Cities and Towns Counties, Joint Regional Agencies,
Metropolitan Sewerage Districts,
Public Health Authorities, Sanitary Districts,
Water and Sewer Authorities
North Carolina League of Municipalities North Carolina Association of Counties
Attn: Wanda Veasey Attn: Lisa Nolen
P. O. Box 3069 215 N. Dawson Street
Raleigh, N.C. 27602-3069 Raleigh, N.C. 27603