Michigan > Local County > Oakland > Family Division
Child Care Verification - Michigan
| Child Care Verification Form. This is a Michigan form and can be used in Family Division Oakland Local County . |
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STATE OF MICHIGAN SIXTH JUDICIAL CIRCUIT OAKLAND COUNTY FRIEND OF THE COURT P.O. BOX 436012 PONTIAC MI 48343 Plaintiff name FRIEND OF THE COURT CASE QUESTIONNAIRE PAGE 1 CASE NO. TELEPHONE NUMBER (248)858-0424 Defendant name 1. Your full name 2. Date of birth 3. Place of birth: city & state 4. Mailing address and residence address (if different) 5. Sex M 6. Eye color F 7. Hair color 8. Height 9. Weight 10. Race 11. Scars, tattoos, etc. 12. Home telephone number 13. Father's full name 14. Work telephone number 15. Mother's full maiden name 16. Names of all your dependant children Birth date Social Security No. Address Natural/step/adopted 17. Are you or the other parent in this case pregnant? A. When is the child due? Yes No If yes, complete sections A and B below. B. Are the parties in this case the biological of the expected child? INFORMATION REGARDING THE OTHER PARENT IN THIS CASE (IF KNOWN) 18. Full name 19. Date of birth 20. Place of birth: city & state 21. Mailing address and residence address (if different) 22. Social Security No. 24. Home telephone 26. Sex M F 27. Eye color 28.Hair color 29. Height 23. Driver's License No. 25. Work telephone 30. Weight 31. Race 32. Scars, tattoos, etc. 33. Father's full name 34. Mother's full maiden name 16. Names of all your dependant children Birth date Social Security No. Address Natural/step/adopted Is the other parent in this case married? Yes No 2001 © American LegalNet, Inc. STATE OF MICHIGAN SIXTH JUDICIAL CIRCUIT OAKLAND COUNTY FRIEND OF THE COURT CASE QUESTIONNAIRE PAGE 2 CASE NO. INCOME INFORMATION 36. Your occupation CHECK YOUR INCOME TAX FILING STATUS: MARRIED SINGLE HEAD OF HOUSEHOLD NO. OF DEPENDANTS CLAIMED: 37. Your employer (if unemployed, name of last employer) 38. Employer's address City State Zip 39. Date hired 40. Gross earnings per pay period (earnings before taxes) $ Weekly Bi-weekly 42. Hourly pay rate $ (including shift premium & COLA) 45. Second job 47. Employer's address City 46. Employer State 41. Social Security No. Bi-monthly Monthly 44. Average overtime hours for past 12 months 43. Total regular hours worked per pay period Zip 48. Date hired 49. Gross earnings per pay period (earnings before taxes) $ Weekly Bi-weekly 50. Hourly pay rate $ (including shift premium & COLA) Bi-monthly Monthly 51. Total regular hours worked per pay period 52. List MONTHLY income from all other sources, such as: ______________________________ Commissions ______________________________ Bonuses ______________________________ Profit Sharing ______________________________ Interest ______________________________ Dividends ______________________________ Annuities ______________________________ Pensions/Longevity ______________________________ Deferred Compensation/IRA ______________________________ Trust Funds ______________________________ Unemployment Benefits ______________________________ Strike Pay ______________________________ SUB Pay ______________________________ Sick Benefits ______________________________ Worker's Compensation 53. Do you have any other alimony or child support orders? If yes, complete sections 53 A, B & C below A. Amount of order $ (do not include arrearages) Yes, as payor Social Security Benefits Supplemental Security Income (SSI) V.A. Benefits Disability Insurance G.I. Benefits National Guard & Reserve Drill Pay Armed Services Allowance for Rent Rental Income Spousal Support/Alimony General Assistance AFDC Other: ____________________ Other: ____________________ Yes, as recipient No ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ __________________ B. Type of order/case no. C. City, County & State 54. Do you provide the sole support for stepchildren residing in your home because support is unavailable from both natural/adoptive parents? Yes No If yes, how many stepchildren do you support? ____________________ If yes, state the reason the step children's mother is unable to provide support: If yes, State the reason the step children's father is unable to provide support: 55. Do any of the children listed on item 18 receive payments from the Social Security Administration? Child's name Amount (Monthly) Type of benefit SSI Dependent Benefit Yes No Source of dependent benefit (Mother, father, stepparent) 56. ATTACH YOUR 4 MOST RECENT PAYCHECKS STUBS, ON A STATEMENT FROM YOUR EMPLOYER(S) OF WAGES AND DEDUCTIONS, AND YEAR-TO-DATE EARNINGS, AND A COPY OF YOUR LAST FEDERAL AND STATE INCOME TAX RETURNS, INCLUDING ALL SCHEDULES. IF SELF-EMPLOYED, ALSO ATTACH A COPY OF YOUR 3 MOST RECENT BUSINESS TAX RETURNS ANS/OR CORPORATION RETURNS. 2001 © American LegalNet, Inc. STATE OF MICHIGAN SIXTH JUDICIAL CIRCUIT OAKLAND COUNTY FRIEND OF THE COURT CASE QUESTIONNAIRE PAGE 3 INCOME INFORMATION OF OTHER PARENT IN THIS CASE (IF KNOWN) CASE NO. 56. Occupation 57. Employer (if unemployed, name of last employer) 58. Employer's address City State Zip 59. Hourly pay rate $ (including shift premium & COLA) 60. Gross earnings per pay period (earnings before taxes) $ Weekly Bi-weekly Bi-monthly Monthly 61. Average overtime hours for past 12 months HEALTH CARE INFORMATION 62. Medical insurance company name Policy no. Beginning date, if known 63. Dental insurance company name Policy no. Beginning date, if known 64. Optical insurance company name Policy no. Beginning date, if known 65. What dependent coverage is available by payment of an additional premium? (Specify cost per pay period): Medical $ 66. Individuals currently covered by your insurance: Name Birth date Relationship Medical Dental Optical Dental $ Optical $ CHILD CARE INFORMATION 67. Do you have child care expenses for the minor children in this domestic relations case during any time of the year? If yes, complete the following information: Name of child care provider Yes No Names of children receiving child care No. of weeks provided during last calendar year Estimated no. of weeks of child care provided in this calendar year Current weekly child care cost Amount of child care credit received on last year's federal IRS return 68. Check the reason(s) which explain why you need childcare and estimat
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