Fillable Debt Referral Quesonnaire (Minnesota Department of Revenue)

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Debt Referral Quesonnaire (Minnesota Department of Revenue)

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Agency
Agency already refers debts to the Minnesota Department of Revenue
New Agency
Department/Division FEIN
Mailing Address City State ZIP Code
Debt Referral Quesonnaire
Your Three Digit Code Your Agency Name
Debt Type
Descripon
Debt Type Name Descripon (descripon may be included on correspondence to the debtor.)
Example of a name and descripon:
Debt Type Name: General Accts Recvble Debt Type Descripon: Failure to pay general account receivables, which may include tuion, fees, nes, NSF checks and/or other charges.
Legal Informaon
1 When do your debts become past due? (A specic date? A certain number of days?).. 1
2 What statute authorizes assessment of the debt type? ........................... 2
3 What are the appeal rights for the debt type? ..................................3
4 Do you assess ocers of businesses for personal liability? Yes No
Stascs
1 What is the demographic composion of this debt type? ........................ 1 Business % Individuals %
2 What is the esmated number of referrals? ................................... 2 Inially Annually
3 What is the average dollar amount of the debts? ............................... 3
Debt Type Components
What are the components of the debts? (Check all that apply)
Principal Penalty Interest* Fees/Costs**
*If you checked the Interest box, complete the secon below on Interest.
** If you checked the Fees/Costs box, complete the secon below on Fees/Costs.
Interest
Our system will calculate and track interest for the debt type. Does interest accrue daily? Yes No
If no, please explain:
Is interest compounded? (Interest is charged on interest.) Yes No
Check the interest method below:
Fixed interest rate – the interest rate for each debt remains the same for the life of the debt.
Can debts within this debt type have dierent xed rates? Yes No
(For example, debt incurred in 2011 has interest rate of 3%; debt incurred in 2012 has interest rate of 4%.
What is the current annual xed interest rate?
Variable interest rate – the interest rate for each debt may change over the life of the debt. (All debts in this debt type must follow the same
interest schedule. For example rate is 3 percent from January 1, 2017 to December 31, 2017, then 4 percent from January 1, 2018 to present.
What is the current annual interest rate?
How oen can the rate change?
Does your agency refer another debt type to us with the same variable interest schedule as this debt? Yes No
If yes: What is the three digit debt type code? What is the name of the debt type?
Debt Type, Connued
Fees/Costs
Minnesota Statutes, Chapter 16D authorizes the Department of Revenue to charge collecon costs to cover the cost of collecon. Agencies cannot
refer a debt to the department if it includes Collecon Costs. You must remove any of your agency’s collecon costs before referring a debt to us.
If you add any addional fees or costs, answer the quesons below.
1
What is the addional amount called? (for example, fee, penalty, etc.).............. 1
2 What statute authorizes the assessment?...................................... 2
3 What is the rate or amount?................................................. 3
Payo Order
In what order do you apply payments to the debt? (Select one):
Penalty, Interest, Principal, Fees/Costs (this is the most common)
Principal, Penalty, Interest, Fees/Costs
Other (explain, including statutory reference)
Disbursement of Payments
Payments to you are made through the state wide accounng system, SWIFT. Please complete the informaon below:
How will you recieve payment? (Select one):
Cash Receipt (your individual debtors and debts are in SWIFT)
We will post directly to the debt. (1, 6, 7, and 8 required below)
Cash Receipt Correction (your agency is in SWIFT, but your individual debtors are not)
We will send a lump sum payment to your SWIFT account (1 through 8 are required below)
Vendor (Neither your agency nor your debtors are in SWIFT)
We will send a lump sum payment to your Vendor ID (9 and 10 are required below)
SWIFT Informaon
Fill out all that apply. Contact Minnesota Management and Budget for this information if you do not have it.
1. SWIFT Business Unit: 5 characters
2. SWIFT Account: 6 characters
3. SWIFT Department ID: 8 characters
4. SWIFT Fund: 4 characters
5. SWIFT Appropriation ID: 7 characters
6. SWIFT Deposit Unit: (If used) 5 characters*
7. SWIFT Midas Location: 8 characters*
8. SWIFT Bank Code: 5 characters
9. SWIFT Vendor ID
10. SWIFT Vendor Location
Note: The rst three characters of the SWIFT Midas Locaon must match the rst three characters of the SWIFT Deposit Unit.
Method of Referral
How will you refer debts to us? (Select one):
e-Services – an online system where you directly enter the informaon for each debt. This is most common for agencies with fewer cases. We
will set up an online account for you to refer new debts, change referred debts, and report payments made.
Virtual Room – A systemac process where you upload data les with informaon for mulple debts. Data les must match our le layout. If
you choose this opon, we will provide the le layout requirements. Virtual Room is generally for agencies with many cases which makes it
inecient to manually enter and update debt informaon. If this is your choice please provide the following:
Technical Contact Name:
Phone:
Email:
Debt Referral Quesonnaire, connued
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Debt Referral Quesonnaire (Minnesota Department of Revenue)

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Completed 20 November 2020

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