2025 Annual Participation Form

1) Date
2) Local Government Name
3) Type of Participant City/Town/Village
County
Water & Sewer (162A Art. 1)*
Joint Regional Agency (160A Art. 20)
Public Health Authority (130A - Art. 2, Part 1B)
Metropolitan Sewerage District (162A Art. 5)
Sanitary District (130A Art. 2, Part 2)
Housing Authority (157)
Reg. Solid Waste Auth. (153A Art. 22)

* if a municipality providing Utilities - select City/Town/Village, not Water & Sewer (162A Art. 1)
4) Coordinator Name

Main contact for the Clearinghouse
5) Coordinator Phone Number
6) Coordinator Email address
7) Coordinator Email address (re-enter for verification)
8) Coordinator Mailing Address
9) Contact Name

 Contact for debtors. May be the same person as Coordinator

 
10) Contact Phone Number
11) Contact Email Address
12) Contact email address (re-enter for verification)
13) Hearing Officer and Title/Position
14) Name and/or Department for Debtors to be referred to when calling the Interactive Voice Response (IVR)
15) Telephone Number for Debtors to be referred to when calling the Interactive Voice Response (IVR)
16) Would you like different contacts and phone numbers for different departments/types of debt? No - just 1 needed
Yes- please contact Coordinator to discuss
Already Set-up-No changes needed at this time
Already Set-up-Have changes, please contact Coordinator
17) Current Method for Transmitting Debts (if already participating) or Choice (if not yet participating) Client Software: Encrypted Data and Encrypted File Transfer (No Cost)
Secure Web Access: Encrypted File Transfers: ASCII ONLY (No Cost)
Hardcopy Forms by Secure Fax (No cost for 50 debtors or less)
18) Type of Debt(s) currently being submitted (for information only) Taxes - Property
Taxes - Vehicle
Utilities
EMS
Health
Alarms
Animal violations
Assessments
Civil citations
Code enforcement
Demolitions
Employees
Environmental
Fines (library/other)
Housing
Inspections
Landfill
Loans
Maintenance (lawn,trees)
Nuisance
Ordinance violations
Parking tickets
Privilege license (debts prior to 6/30/2015)
Recreation
Returned checks
Sewer tap
Solid Waste
Storage rental
Storm water
Traffic citations
None (a new participant)
19) Other types of debts not listed above
20) Name of Person completing this form
21) Title of Person completing this form
22) Email Address of person completing this form

Instructions for Completion and Submission:

a) Complete items 1 - 22 above

b) Click "Submit Form" (REQUIRED) which will submit and clear all entries. Clicking SUBMIT prior to PRINT requires a re-start.

c) An official 2025 Participation Form will be electronicaly mailed to the email in #22. The form must be electronically signed by a local government official. A signed original NO LONGER needs to be mailed.