Michigan > Statewide > Domestic Relations > Investigation
Employers Disclsoure Of Income And Health Insurance Information FOC 22a - Michigan
| Employers Disclsoure Of Income And Health Insurance Information Form. This is a Michigan form and can be used in Investigation Domestic Relations Statewide . |
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Approved, SCAO STATE OF MICHIGAN COURT CASE NO. JUDICIAL CIRCUIT EMPLOYERS DISCLOSURE OF INCOME AND COUNTY HEALTH INSURANCE INFORMATION Friend of the Court address Telephone no.The information obtained will be treated as confidential and shall not be used or released except for the purposes of administering,enforcing, and complying with state and federal laws governing child support. Name of FOC employee (type or print) Title Telephone no. Date 1. Employee name 2. Address 3. Social security number 4. Employer name 5. Employer address 6. FIA Case no. Complete items 7, 8, and 9 if insurance is available to employee. 7. Medical insurance company name, address, telephone no. Policy number8. Dental insurance company name, address, telephone no. Policy number9. Optical insurance company name, address, telephone no. Policy number10. What dependent coverage is automatically available? Medical Dental Optical 11. What dependent coverage is available by payment of an additional premium? Specify cost to employee (per individual per family) Medical per Dental per Optical per 12. What dependents of employee are covered? Effective Date of Coverage Name DOB Relationship Medical Dental OpticalSign and return to the Friend of the Court address listed above. Use other side if necessary. See notice on other side.Date Name and signature of person preparing form Telephone no. FOC 22A (6/99) EMPLOYERS DISCLOSURE OF INCOME AND HEALTH INSURANCE INFORMATION <<<<<<<<<********>>>>>>>>>>>>> 2 NOTICE TO EMPLOYERUnder Michigan Law you are required to provide information relative 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 formeremployer 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 employedas 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 shallbe reported, regardless of method of payment. (e) The following information concerning the persons current and former employment status: whether or not the custodialparent or absent parent is currently employed, laid off, or on sick, disability or other leave of absence, or retired and the amount ofincome 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. Use this space for any necesesary explanations from other side
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