DHS-681/FEN681 MS Word (Rev. 8-13) 1
REQUEST TO DISCHARGE STATE-OWED DEBT
If you think you have good reasons for the Friend of the Court (FOC) to discharge (forgive or waive) your state-owed debt,
please complete all information on this form, and return it to the FOC office where your court order is located. You may include
more pages if you need more space. You may be asked to fill out more paperwork or provide proof of any of this information.
FOC staff may schedule a follow-up meeting with you in person or by phone.
If you have a court order in more than one county, please provide a copy of this form to each FOC office where you are
seeking discharge of state-owed debt.
PERSONAL INFORMATION
Name
Date of birth
Social Security number
Driver’s license or state ID number
Address
Email
Home phone
Cell phone
Custodial party name(s) or docket number(s) (if known)
YOUR SITUATION
Below, please list who lives with you in your household, including children.
Age
How is this person related to you?
Does this person have income/
help pay household expenses?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
1.
In your living situation, do you:
Rent
Own
Other
If other, please explain:
2.
Do you have any child support cases in other states?
Yes
No
If yes, which state(s)?
Case number(s) if known:
3.
How much can you pay in current child support?
$
/month
4.
How much can you pay toward past-due support?
$
/month
5.
Would you be able to pay at least $1,000 at one time if the FOC “matched” the payment amount by discharging an
equal amount of your state-owed debt?
Yes
No
If no, what amount could you pay all at one time to qualify for a matching discharge?
$
MAURA D. CORRIGAN
DIRECTOR
RICK SNYDER
GOVERNOR
S
TATE OF
M
ICHIGAN
DEPARTMENT OF HUMAN SERVICES
L
ANSING
DHS-681/FEN681 MS Word (Rev. 8-13) 2
6.
Please select your highest level of education:
Some high school
Two-year college degree (associate’s)
High school diploma/GED
Four-year college degree (bachelor’s)
Some college
Graduate degree (master’s, J.D., etc.)
7.
Do you have any specialized job training or licenses (examples: apprenticeship, certification, etc.)?
Yes
No
If yes, please describe:
8.
Are you currently employed:
Full-time
Part-time
Unemployed
If unemployed, are you eligible for unemployment benefits?
Yes
No
If no, why not?
If unemployed at any time in the past three years, please identify below which months you were unemployed and not
receiving unemployment benefits. (You weren’t eligible for benefits, or they had run out.)
(Examples: 1/2011, 4/2012, etc.)
9.
Current employer name and address, if you have one:
Employer phone:
10.
Are you currently incarcerated (in jail or prison)?
Yes
No
If yes, please complete the following:
Prisoner ID:
Date you expect to be released:
Prison/Jail location:
11.
Have you been incarcerated in the past?
Yes
No
If yes, please list approximate start and end dates:
Start:
End:
Start:
End:
Start:
End:
12.
If you answered yes to Question 11, is it hard for you to find employment because of previous jail, prison, or probation
sentences?
Yes
No
If yes, please explain:
DHS-681/FEN681 MS Word (Rev. 8-13) 3
13.
Are you receiving Social Security payments?
Yes
No
If yes, please provide a copy of your award letter or other proof to the FOC with this form, and complete the following:
Date you began receiving payments:
Type of payments:
SSI
Disability
Retirement
Are you permanently disabled according to the Social Security Administration (SSA)?
Yes
No
If yes, please provide proof to the FOC with this form.
14.
Do you have a disability or other health issue(s) that may prevent you from working full-time, or from working at all?
Yes
No
If yes, please provide proof to the FOC with this form.
15.
Do you currently receive public assistance (FIP, Medicaid, Food Stamps, etc.)?
Yes
No
If yes, what kind of assistance?
16.
Are you currently under a bankruptcy plan, or are you in the process of filing for bankruptcy?
Yes
No
17.
Do you expect to receive money from a will, estate, or trust?
Yes
No
18.
Are you currently living in a homeless shelter or taking part in a homelessness program?
Yes
No
If yes, length of time:
19.
In the past six months, have you been unable to pay medical bills (for either yourself or a family member) that you
must pay?
Yes
No
20.
In the past six months, have you been unable to pay other bills that you must pay?
Yes
No
If yes, list bills you are unable to pay:
21.
Do you spend time with your child(ren) on a regular basis, attend school activities, and/or consistently exercise your
court-ordered parenting time?
Yes
No
22.
In addition to your regular parenting time schedule, do you care for your children while the other parent is at work,
at school, etc.?
Yes
No
If yes, list how many hours you do this per week:
23.
Do you provide non-money support (examples: transportation, clothing, etc.) to your children?
Yes
No
24.
Would you be willing to take a finance or budget class?
Yes
No
25.
Would you be willing to attend a jobs program?
Yes
No
26.
Would you be willing to do volunteer work?
Yes
No
If yes, how many hours per week are you willing to volunteer?
MONTHLY INCOME INFORMATION (List gross amounts before taxes)
Income from job(s)
Workers compensation
Social Security (SSI, disability, retirement, etc.)
Veterans Administration (VA) benefits
Unemployment
Pension
Child support received (for all cases)
Spousal support
Settlement (legal settlement, insurance settlement, annuity)
Other income (describe source and monthly amount)
DHS-681/FEN681 MS Word (Rev. 8-13) 4
ASSET INFORMATION
Do you have a savings, checking, or other non-retirement account?
Yes
No
If yes, total amount in all accounts:
$
Date:
Bank or financial institution name:
Do you have retirement savings such as 401(k)?
Yes
No
If yes, total amount in all retirement accounts:
$
Date:
Bank or financial institution name:
Do you own or lease a car or truck?
Yes
No
If yes, number of cars/trucks owned or leased:
Do you have any of these items worth over $500?
Computer/Tablet:
Yes
No
Snowmobile:
Yes
No
Boat:
Yes
No
Jewelry:
Yes
No
Camper:
Yes
No
Tools:
Yes
No
Motorcycle:
Yes
No
Other:
Yes
No
AVERAGE MONTHLY EXPENSES (your share or the amount you pay)
Rent/mortgage
Electric
Cable/satellite TV
Water
$
$
$
$
Natural gas/oil
Child support
Phone (home/cell)
Credit cards
$
$
$
$
Medical bills
Car payments
Child care
Education
$
$
$
$
Spousal support
Insurance (car, life, medical, homeowners)
Other monthly payment(s) (describe)
$
$
$
DEBTS (your share or the amount you pay)
Total balance on credit card(s)
Date
Total balance on medical bills (self)
Date
Total balance on medical bills (family)
Date
$
$
$
Do you owe restitution as a result of a crime?
Yes
No
If yes, amount owed:
$
Do you owe fees, fines, and/or court costs?
Yes
No
If yes, amount owed:
$
Do you owe someone as a result of a court judgment?
Yes
No
If yes, amount owed:
$
Please note that if any of your state-owed debt is discharged based on incorrect, incomplete, or false information you
provided, the FOC may reinstate the debt forgiven (add it back to the total amount owed in support).
Please sign below to indicate that you believe the information you have provided on this form is correct and complete.
Signature
Print Name
Date
Department of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight,
marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the
Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area.
C:\Users\Jill Proctor\AppData\Local\Microsoft\Windows\Temporary Internet
Files\Content.Outlook\CSYSNTS5\DHS 681 ADDENDUM.DOCX
DHS 681 ADDENDUM
1.) DO YOU RECEIVE ANY INCOME (PER CAP) AS A BENEFIT OF BEING A TRIBAL MEMBER?
YES NO IF YES, HOW MUCH?
2.) HAVE YOU FILED OR DO YOU INTEND ON FILING A LAW SUIT FOR A MONETARY
AWARD/SETTLEMENT?
YES NO IF YES, WHO IS YOUR ATTORNEY?
3.) DO YOU HAVE ANY OF THE FOLLOWING? IF YES, PLEASE ATTACH COPIES.
A.) YES NO MEDICAL EXPENSES
B.) YES NO OVER DUE BILLS
C.) YES NO PAY STUBS FROM ANY AND ALL SOURCES OF INCOME
D.) YES NO SOCIAL SECURITY AWARD LETTER
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