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2001 Participation Form <br />NC Local Government Debt Setoff Clearinghouse Program <br /> <br />This certifies that the following local government entity intends to Pmiticipate in the Local <br />Government Debt Setoff Collection Program for the 2001 calendar year: <br /> <br />I <br />I <br />I <br /> <br />.Name of Local Government: Date: .' <br /> Phone: Email: <br /> <br />Local Debt Setoff <br /> <br />Coordinator: <br /> <br />Mailing Address: <br /> <br />The local debt setoff coordinator will receive all communications and is authorized t° carry out the <br />requirements of the Debt Setoff Act and any agreements entered herein to enable participation in debt <br />setoff. <br /> <br />Local Debt Setoff Contact: Phone: <br /> <br />Mailing Address: <br /> <br />Email: <br /> <br />The local debt setoff contact will be referred all calls from debtors via the automated v~ice response <br />system. <br /> <br />Local Debt Setoff Pl3one Number for Debtor Contact: <br /> <br />This phone number will be provided to debtors via the automated voice response system <br /> <br />Please choose an option for data transmission by checking the appropriate box: <br /> I <br />Customized Software: File Transfer Protocol: [ Hardcopy: <br /> (will require <br /> , cntr7 costs) <br /> <br />payment <br /> <br />(authorized official), attests that our local government <br /> <br />will follow the written notice and heating requirements pursuant to GS 105A-5, prior to <br /> <br />transmitting any debts to the CLEARINGHOUSE for submission for debt setoff. <br /> <br />of data <br /> <br />~-'" ~ Addendum A - 12 <br /> <br /> <br />