23.2.404 FORMS
(1) The department shall refer a debt to the
department of administration, or other agency designated by law, on the
attached form.
BAD DEBT CERTIFICATION
& TRANSFER FORM
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Agency Name:
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(Department Use Only)
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Document Locator No.
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Instructions:
Prepare five copies, keeping the last copy for agency file; send
remaining four copies to the Department of Administration, Debt Collection
Services, Mitchell Building, Helena, MT 59620. A complete file on bad debt
must accompany form. See MOM Chapter
2-1100 for necessary instructions.
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Agency Document No.
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No Warrant Trans. Doc. No.
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DATA PROCESSING
ENCODING SUMMARY
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Agency No.
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Accounting Entity
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Principal Amount Due
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Account Name
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02
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Interest
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Penalties
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Other Charges
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Account Address
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Social Security No.
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Employer I.D. No.
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HISTORY OF COLLECTION
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ORIGINAL TRANSACTION
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Date
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Debt Description
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Debt Code
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Principal Amount Due
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Annual Interest %
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Interest
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Penalties
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Other Charges
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Total Amount Due
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AGENCY COLLECTION
PROCEDURES
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Date of First Notice
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Check appropriate box:
G Demand for payment was sent to debtor's
last known address, but debtor cannot be contacted there;
G Debtor has been offered an appropriate
installment payment schedule, but Debtor has declined to agree to the
schedule; or
G Although Debtor agreed to an installment
schedule, Debtor has not made an installment payment within ten days of the
Department's demand letter providing notice of delinquency.
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Date of Final Notice
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CERTIFICATION AND
TRANSFER
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I hereby certify this
to be a valid debt of the State of Montana and that every means of collection
of the Account Receivable identified herein has been utilized according to
agency criteria for uncollectibility.
This notice will evidence our intent to transfer this debt to the
Department of Administration, Debt Collection Services.
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Signature of Agency
Official Title Date
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ACCEPTANCE AND WRITE
OFF AUTHORITY
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G Approved We hereby accept this debt.
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G Not Approved See attached material.
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Signature of Agency
Official Title Date
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History: 2-4-201, MCA; IMP, 17-4-110, MCA; NEW, 1999 MAR p. 984, Eff. 5/7/99.
