Fill and Sign the North Carolina Debt Setoff Program North Carolina Tax Form

Deputy CSC Assistant CSC Clerk Of Superior Court Clerk Of Superior Court Assistant CSC STATE OF NORTH CAROLINA AM PM Date Signature Deputy CSC Signature Original-File Copy-Taxpayer Copy-AOC(Over) NOTICE OF HEARING SETOFF DEBT COLLECTION County G.S. 105A-8 TO: Taxpayer listed above above will be held on the date and at the time and location shown below. At the hearing, either party may appear in person or through an attorney and present evidence and arguments. If the taxpayer fails to appear or if, after the hearing, the State's claim is f ound to be valid, the entire amount, including interest, which is owing on that claim will be offset against any income tax refund otherwise due the taxpay er. Time Of Hearing Date CERTIFICATE OF SERVICE Name And Address Of Claimant Agency Administrative Office of the Courts Raleigh, NC 27602 NOTE TO CLERK: VERSUS Administrative Office of the Courts, Claimant Agency Name And Address Of Defendant/Taxpayer Social Security No. Date Of Hearing Location Of Hearing I certify that on the date shown below a copy of this Notice was served on each party by depositing a copy in the United States mail in an envelope bearing proper postage and addressed as f ollows: Name Of Defendant/Taxpayer A hearing on the validity of the claim of the State of North Carolina to the income tax refund due to the taxpayer named P.O. Box 2448 FAX: (919) 890-1959 Serve copies on parties by first class mail. Place original in current year's file for contested tax setoff claims. See reverse side for final decision to be entered after hearing. COVER SHEET NOT REQUIRED ***FAX COPY OF NOTICE OF HEARING TO SETOFF DEBT DEPT. AT (919) 890-195\ 9 AOC-G-900M, Rev. 10/11 © 2011 Administrative Office of the Courts Setoff Debt Collection Dep artment File No s. Assistant CSC Clerk Of Superior Court Magistrate TOTAL DEBT STATE OF NORTH CAROLINA Upon due notice , a hear ing was held on the date shown below on the contest ed claim of the claimant agency, named above to t he North Carolina income tax ref und due t o t he t axpaye r named above. T he t axpayer appear ed in court or thr ough an attorney. did not appear. The claimant agency was represent ed by All interest is waived a fter due considerat ion of the facts o f the case and in accor dance with policies adopted by t he This claim is denied and this seto ff debt collect ion proceeding is dismissed. Pursuant to G.S. 105A- 10, the Administrative Office of the Courts shall r efund t he curr ent year's t ax ref und t o t he defendant.. It is O RDERED that: Pursuant to G.S. 105A-8 the Administrative Office of the Courts is entitled to t he "Tot al Debt" shown below. a valid claim f or the "Tot al Debt" shown below. not a valid claim. FINAL DECISION ON CONTESTED CLAIM SETOFF DEBT COLLECTION T his Order constitutes a final decision in a contest ed case within t he meaning o f G.S. 150B- 43. The parties have ex haust ed all administrative remedies available t o t hem under the North Carolina Seto ff Debt Collect ion Act. Any party aggr ieved by t his decision is entitled to judicial r eview of the decision as provided in Article I V of the North Carolina Administrative Procedure Act (Chapte r 150B o f the North Carolina G eneral Statutes). County Administra tive Office o f the Courts, Claiman t Agency G.S . 105A-8 was not represent ed. On the basis o f the entire record in this case and the evidence and arguments present ed, if any, the undersigned hearing o ffice r finds t hat the claim, as set forth in the Notice Of Claim To Income Tax Refund on record , is: VERSUS DO CKET R EFERENCE AMOUNT OWIN G ON JUDGMENT $ $ $$$ County Case File Judgment Book Page Principal Amount As Docketed Pay ments To Date Interest To Date JudgmentTotal Signature Of Hearing Officer Date Of Decision Name And Address Of Defendant/Taxpayer Social Security No. Date Of Hearing AOC -G-900M, Side Two, Rev. 10/11 © 2011 Administrative Office of the Courts ***FAX COPY WHEN HEARING IS FINALIZED TO SETOFF DEBT DEPT. AT (919) 890-1959-- COVER SHEET NOT REQUIRED . Office o f Indigent Defense Services. To access those policies, go to www.ncids.org , place cursor over "Information for Counse l," select "Policies and Procedures " from the menu, and select "Recoupment: Attorney Fee Judgments and $60 Appointment Fee. " File No s.