We provide the forms you as local governments need to successfully take part in the Debt Setoff program. Access and download the forms from this page. Below offers an overview of all forms.
Participation Form – Required annually, this form allows you begin submitting debts at the end of the calendar year through the next year (covers September through December of the following year). It provides your contact information to debtors who call our Interactive Voice Response system with questions about debts you've submitted to the Clearinghouse.
Participants’ debts will not be sent to the Department of Revenue and Education Lottery until the form is submitted.
Changes to contacts, emails or phone numbers after the participation form is submitted can be made online by resubmitting the form.
Initial Sign-Up Forms
These include the Memorandum of Understanding, Local Agency Certification and the Multiple Unit Collection Rider and must be sent either to North Carolina League of Municipalities (cities and towns) or North Carolina Association of County Commissioners (counties and all others).
For EMS/Health Debts
A Business Associate Rider is required for all participants that will submit EMS and/or health debts. Contact Scott Kauffman at 323 W. Jones St, Ste 500, Raleigh 27609 or Scott.Kauffman@ncacc.org for the form.
Notification Letters
Notification letters, by statute, must be detailed and describe each debt. The type of debt (or department), description of the debt, account number and amount of debt is required. We provide four samples in the format of the letters in the client software. The Clearinghouse does not generate notification letters for debtors without Social Security numbers, nor does it generate notification letters for data entry participants.
Other Forms and Documents
We also provide a sample resolution for your governing board, sample appeals documents and other specialized documents to help your process run smoothly.