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Employers Disclosure Of Health Insurance And Or Income Information FOC 22 - Michigan

Employers Disclosure Of Health Insurance And Or Income Information Form. This is a Michigan form and can be used in Investigation Domestic Relations Statewide .
 Fillable pdf Last Modified 12/16/2013
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Approved, SCAO STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY Friend of the court address EMPLOYER'S DISCLOSURE OF HEALTH INSURANCE AND/OR INCOME INFORMATION CASE NO. Telephone no. NOTICE TO EMPLOYER Under Michigan law, you are required to provide information as it relates to the custodial or absent parent as follows: Sec. 18.(1) Subject to subsection (3) and (4), upon the request of the office of the friend of the court, any employer or former employer of a parent as defined in section 1 of the office of child support act, 1971 PA 174, MCL 400.231, who is or was employed as an employee or independent contractor, shall provide the following information relative to the custodial parent or absent parent: (a) Full name and address. (b) Social security number (unless the parent is exempt under state or federal law). (c) Date of birth. (d) Amount of wages earned by or other income due the custodial parent or absent parent. Both net and gross income shall be reported, regardless of the method of payment. (e) The following information concerning the person's current and former employment status: whether or not the custodial parent or absent parent is currently employed, laid off, or on sick, disability, or other leave of absence, or retired and the amount of income due from an employment-related benefit plan, if any. (f) Dependent health-care coverage available to the custodial parent or absent parent as a benefit of employment. Return this completed form to the friend of the court at the above address. Date Name of person preparing form (type or print) Telephone no. The information obtained from this disclosure form will be treated as confidential and will not be used or released except for the purposes of administering, enforcing, and complying with state and federal laws governing child support. Name of contact (type or print) 1. Employee name 3. Social security number 6. Employer address 4. Employer name Title 2. Address 5. Employer federal identification no. Telephone no. Date 7. Check all that apply Employer offers a medical flexible spending account. Dependent insurance not offered to employees. (Skip to item 13.) Dependent insurance medical dental optical is offered to the employee but the employee has not enrolled. (Attach information regarding dependent coverages and cost.) Employee will be eligible for dependent insurance. Date available: (Attach information regarding dependent coverages and cost.) Employee has enrolled for dependent insurance. (Complete items 8 through 12. If you need additional space, use the other side) 8. Medical insurance company name, address, telephone no. Policy no. and Group no. 10. Optical insurance company name, address, telephone no. Policy no. and Group no. 11. What dependent coverage is offered? Specify cost to employee employee only individual plus one per family 9. Dental insurance company name, address, telephone no. Policy no. and Group no. Medical $ Name per DOB Dental $ Relationship per Medical Optical $ Dental per Optical 12. What dependents of employee are covered? Effective Date of Coverage Complete the Income Information on the other side. FOC 22 (3/13) EMPLOYER'S DISCLOSURE OF HEALTH INSURANCE AND/OR INCOME INFORMATION American LegalNet, Inc. www.FormsWorkFlow.com 13. Hourly base pay 14. Shift premium 20. No. weeks paid this yr. 21. Date hired 15. COLA 16. Avg. overtime 17. W-4 Exemp. 18. Reg. work hours 19. Pay period (weekly, etc.) $ /week /week 24. Is this person receiving unemployment benefits? 22. Date of term. (if appl.) 23. Reason for leaving Yes No Calculate year to date figures as of last pay period. 25. INCOME Reg. Earnings (incl. shift prem. and COLA) Overtime Commissions Pension and and Bonuses Longevity Profit Sharing Other (explain) Gross Deferred income in addition to gross Year to Date Last Calendar Year 26. OTHER INCOME Year to Date Last Calendar Year 27. Disability Workers Comp. Sick Pay SUB Pay Disability carrier Worker's compensation carrier WITHHOLDING Federal Income Tax F.I.C.A. State Income Tax Local Income Tax Mandatory Professional or Union Dues Alimony and Child Support Mandatory Withholding (explain) Year to Date Last Calendar Year Return this completed form to the friend of the court at the address on the other side. Use this space for any necessary explanations from the other side. American LegalNet, Inc. www.FormsWorkFlow.com
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