State of Michigan department of HEALTH AND human services Lansing GRETCHEN WHITMER governor ELIZABETH HERTEL director
Emergency Notice of Withdrawal of Passport Denial
Office of Child Support Enforcement Federal Collections and Enforcement, 2nd Floor 370 L’Enfant Promenade, SW Washington, DC 20447	Date:
RE: Obligor
Social Security Number	Telephone Number	Date of Birth	Place of Birth
Regional Passport Agency or U.S. Embassy/Consulate General/Out of Country
The state requests that the above-named individual be released from the Passport Denial Program remedy for the following reason:
Life or Death Situation: The state has the documentation verifying the legitimacy of this situation.
Erroneous Submittal of Social Security number
Mistaken Identity: The above-named individual has never had a child support case submitted to the Office of Child Support Enforcement (OCSE). The U.S. Department of State passport application denial letter must be attached along with the individual’s Social Security number, date of birth, place of birth and phone number.
Obligor Out of Country
The obligor made the following arrangement(s):
Purpose and Destination of Travel (Business, Vacation, Wedding, Honeymoon, etc.):
Lump-Sum Payment:	$
Other:
The applicant is aware that this action should not be construed as a satisfaction of the child support debt nor a withdrawal of other applicable enforcement actions. The applicant is also aware that this form will not be accepted (either in person or by mail) by the passport agency as proof that (s)he has been withdrawn from the Passport Denial Program. In addition, after OCSE has lifted the hold on the applicant’s passport, the applicant is aware that the passport agency will not automatically release the passport until the applicant has notified them either in person, by a representative, or by phone, that his/her case has been cleared.
I certify the information provided above and request that this applicant’s eligibility for issuance of a passport be restored.
IV-D Director or Designee	Telephone Number	Email Address
517-241-2922	mdhhs-ocs-passport@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.