State of Michigan department of HEALTH AND human services Lansing GRETCHEN WHITMER governor ELIZABETH HERTEL director
Request for “Matching” Payment
The Friend of the Court (FOC) office may “match” a payment. This means the FOC may remove one dollar of debt you owe to the State of Michigan for every dollar you pay as a voluntary lump-sum amount, up to the amount owed for state-owed debt. In order to qualify for matching, you must have first completed the Request to Discharge State-Owed Debt (DHS-681/FEN681). The FOC will review the DHS-681/FEN681 to determine if you qualify. Upon approval by the FOC, please complete this form and return it to the FOC with your payment. Please read, complete, and sign the following: I am requesting a match for my payment on my court order:
Name	Docket
Other Parent/Custodian
Child(ren)
I am able to pay $________________ as a one-time payment on my past-due support. I understand that I may not make this request if I purposely failed to pay my child support, or if I have enough money and/or assets to pay all that I owe. I believe the information I have provided on this form is correct and complete. I understand that I must make my payment at the FOC office and include: My name; The amount I am paying; The docket number that my payment applies to; and The name of the other parent or custodian. Otherwise, my payment may apply to other dockets that I have, and my state-owed debt on this docket may not be removed. I understand that if any of my state-owed debt is discharged based on incorrect, incomplete, or false information I provided, the FOC may reinstate the debt forgiven (add it back to the total amount owed in support).
Sign Name	Print Name	Date
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.