Special Instruction Payment Coupon
Michigan Department of Health and Human Services
Today’s Date	Total Payment
I am making this special instruction payment directly to the	County
Friend of the Court as a result of:
Criminal order for non-payment of support (criminal order date:	)
Other:
Apply the total payment as follows (print clearly):
Docket 1
Payer Name	Payee Name
Civil Docket Number	Civil Order Date	Docket County
Apply to Support	Apply to Non-Support (i.e., costs, fees, etc.)
$	$
Docket 2
Payer Name	Payee Name
Civil Docket Number	Civil Order Date	Docket County
Apply to Support	Apply to Non-Support (i.e., costs, fees, etc.)
$	$
Docket 3
Payer Name	Payee Name
Civil Docket Number	Civil Order Date	Docket County
Apply to Support	Apply to Non-Support (i.e., costs, fees, etc.)
$	$
Docket 4
Payer Name	Payee Name
Civil Docket Number	Civil Order Date	Docket County
Apply to Support	Apply to Non-Support (i.e., costs, fees, etc.)
$	$
The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.