EMPLOYER PAYMENT COUPON/REMITTANCE
Michigan Department of Health and Human Services
Michigan State Disbursement Unit
Employer Name	Date of Withholding	Federal Employer Identification Number (FEIN)
Employee Name	Remittance Identifier*	Social Security Number	Amount Withheld
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Total	$
*Found on the Income Withholding for Support form. Mail payments to MiSDU PO Box 30350 Lansing, MI 48909-7850
Attention Employers: This coupon is for making payments on behalf of your employees only. Using this coupon for anything other than its intended purpose may result in payments not being properly applied. Employers are encouraged to visit the MiSDU website at www.misdu.com to learn more about making electronic payments via ACH debit or credit and other electronic payment options available to employers. To contact the MiSDU with questions, call 800-817-0805 option 1, or email MiSDUOutreach@michigan.gov.
The Michigan Department of Health and Human Services will not exclude from participation in, deny benefits of, or discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, gender identification or expression, sexual orientation, partisan considerations, or a disability or genetic information that is unrelated to the person’s eligibility.