2012 Annual Participation Form

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)
Housing Authority (157)
4) Coordinator Name
5) Coordinator Phone Number
6) Coordinator Email address
7) Contact Name
8) Contact Phone Number
9) Contact Email Address
10) Name and/or Department for Debtors to be referred to when calling the Interactive Voice Response (IVR)
11) Telephone Number for Debtors to be referred to when calling the Interactive Voice Response (IVR)
12) Would you like different contacts and phone numbers for different departments/types of debt? No - just 1 needed
Yes- please contact me to discuss
13) Method for Transmitting Debts Client Software (free)
Secure Web Access - send ASCII or Excel (free)
Hardcopy forms (free for < 100 debts)
14) Type of Debt(s) Taxes - Property
Taxes - Vehicle
Utilities
EMS
Health
Animal violations
Assessments
Employees
Fines (library/other)
Inspections
Loans
Maintenance (lawn,trees)
Ordinance violations
Parking tickets
Privilege license
Returned checks
Sewer tap
Solid Waste
Storage rental
Traffic citations
Housing Authority
15) Other types of debts not listed above
16) Name of Person completing this form
17) Title of Person completing this form
18) Email Address of person completing this form
19) Local Government Authorized Official Signature(fill-in once printed)
20) Local Government Agency Manager/Administrator signature (fill-in once printed)
21) Date of Local Government Agency Manager/Administrator signature

The above authorized official attests that our local government agency will follow the written notice and hearing requirements pursuant to GS 105A and the Memorandum of Understanding, prior to submitting any debts to the N.C. Local Government Debt Setoff Clearinghouse.

Instructions for Completion and Submission:

a) Complete items 1 - 21 above

b) Click "Print this Form" 

c) Click "Submit Form"

d) Authorized Official and Local Government Manager/Administrator must sign #19 & 20

e) A signed original MUST be mailed (not faxed) to ONE of the following below:
Cities and Towns
Municipal Housing Authorities

 Counties
Water and Sewer Authorities, Sanitary Districts, Metropolitan Sewerage Districts,
Public Health Authorities, Joint Regional Agencies, Joint Regional Housing 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