ABCDEFGHIJKLMNOPQRSTUVWXYZ
1
All fields must be completed. Note: for additional information about debt forgiveness please refer to the Fiscal Procedures Manual.
2
This workbook is only for debt with supporting documents including but not limited to records of PO, work performed, invoice sent, follow-up with the debtor, etc. Please confirm that debt is substantiated.
(Yes)		Debtor InformationType of Debt
(Note: certain debt is legally uncollectible, such as bankruptcy, deceased debtor, and certain student loans)		 Original Balance Amount Paid Amount to be Forgiven Fund BSADate debt was incurredAge of debt
(Number of years)		Per Fiscal Rule 10-1 debt must be 6 years or greater with no payment activity, offset, or legal action in the past 3 years. Does debt meet this requirement?
(Yes/No)		Has an allowance been recorded in CORE?
(Must be yes in order to be forgiven)		Allowance AmountWhat collection efforts have been made?
(Including results of legal action)		Does the estimated cost of collection exceed the amount of the debt?
(Yes/No)		Is there an actual or apparent conflict of interest?
(Yes/No)		OSC OnlyTreasury Only
3
For Individual Debtor
(Please do not list any information that is protected by law or regulations)
For Business Debtor
(Please provide the information if known, otherwise, indicate "Unknown")		State Controller or Deputy State Controller CommentsState Treasurer or Deputy State Treasurer Comments
4
Is there sufficient information to contact the individual debtor?
(Yes/No)		Individual Debtor Identifier that is not PHI, PII, nor FTIDebtor Business NameDebtor Business AddressDebtor Business EIN
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100