Fill and Sign the Gn 110 Application for Review of Court Debt Offsetpdf Form

OSCA (110-03) GN-110 1 of 1 488.5028 RSMo IN THE CIRCUIT COURT OF COUNTY, MISSOURI Case Number: Case Description: Debtor Name: Case Location: Debtor Party ID: Debtor SSN: Payment Plan Number: Debtor Address & Phone Number: Letter Number: (Date File Stamp) Application for Review of Court Debt Offset I, , (name) received noti ce from the Department of Revenue of a court debt offset with my Missouri state tax refund due to the costs and/or fees and/or fines for the case listed above not being fully satisfied. The date on the Notice of Court Debt Offset is . I am now applying for a review of this court debt offset because this debt was paid on (date). Date Debtor Signature Instructions to Debtor 1. If you have paid the debt owed to the Court for this case or if Court did not order you to pay, this written application must be filed within 30 days of the date of mailing on the Notice of Court Debt Offset with the court in which the debt is owed. The application must include: a. Copies of receipts and/or cancelled checks showing payment made to the court satisfying this debt. b. A copy of the original Notice of Court Debt Offset. 2. A copy of this application must be sent to the Office of State Courts Administrator, Court Debt Offset Program, PO Box 104480, Jefferson City, MO 65110. Notice: Failure to file this application with the court and send a copy to the Office of State Courts Administrator within 30 days of the date of mailing on the Notice of Court De bt Offset that you received from the Missouri Department of Revenue will be deemed a waiver of the opportunity to contest the offset. Results of Court Review of Debt Offset Action (To be completed by the Court.) Upon review of the debtor's Application for Review of Court Debt Offset, the Court finds that the Office of State Courts Administrator should release the Missouri State Tax Refund to the debtor because the delinquent debt for the case has been fully satisfied. the Court because the delinquent debt fo r the case has not been fully satisfied. both the debtor and the Court for partial paym ent as follows: amount to debtor $ amount to Court $ . Allow 30 days for the Office of State Courts Administrator to process the refund. the debtor because the delinquent debt for the case was repo rted in error. Allow 30 days for the Office of State Courts Administrator to process the refund. Date Judge/Clerk A copy of the Results of Court Review of Debt Offset Action must be sent to the debtor and to the Office of State Courts Administrator.