2017 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)
4) Coordinator Name
5) Coordinator Phone Number
6) Coordinator Email address
7) Coordinator Email address (re-enter for verification)
8) Coordinator Mailing Address
9) Contact Name
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 Fax (No Cost-depending on number of debtors/debts)
18) Type of Debt(s) currently being submitted 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) Type of Debt(s) not currently being submitted but planned for near future (optional) 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
20) Other types of debts not listed above
21) Name of Person completing this form
22) Title of Person completing this form
23) Email Address of person completing this form
24) Local Government Authorized Official Name
25) Local Government Authorized Official Signature (fill-in once printed)
26) Date of Local Government Authorized Official signature

The above authorized official attests that our local government agency will follow the written notice and hearing requirements pursuant to GS 105A and the Memorandum of Understanding, prior to submitting any debts to the N.C. Local Government Debt Setoff Clearinghouse.

Instructions for Completion and Submission:

a) Complete items 1 - 26 above

b) Click "Print this Form" 

c) Click "Submit Form"

d) Authorized Official and Local Government Manager/Administrator must sign #25

e) A signed original MUST be mailed (not faxed) to ONE of the following below:

Remember to click "Print This Page" BEFORE clicking "Submit Form". Once "Submit Form" is clicked all the above entries are cleared!
Cities and Towns
Municipal Housing Authorities



 Counties
Agencies: (Water and Sewer Authorities; Sanitary Districts; Metropolitan Sewerage Districts; Public Health Authorities; Joint Regional Agencies; Joint Regional Housing Authorities; Regional Solid Waste Management Authorities)
North Carolina League of Municipalities North Carolina Association of Counties
Attn: Rob Shepherd Attn: Matt Gunnet
150 Fayetteville St, Suite 300 353 East Six Forks Road, Suite 300
Raleigh, NC 27601 Raleigh, NC 276093