Application For IV-D Child Support Services

7 TH JUDICIAL CIRCUIT OF MICHIGAN GENESEE COUNTY FRIEND OF THE COURT MODIFICATION REVIEW REQUEST 1101 BEACH ST. FLINT, MI 48502 810.257.3300 This paperwork should be filled out if you want your child support order to be changed by the Friend of the Court. By law, the Friend of the Court will review child support orders when there is a change in circumstances. By filling out this form, you are telling the Friend of the Court to review your child support order and that you believe there has been a change of circumstances since your last order was entered. CASE NUMBERS: PAYER222S NAME PAYEE222S NAME PHONE NO. PHONE NO. STREET ADDRESS STREET ADDRESS CITY, STATE, ZIP CITY, STATE, ZIP MODIFICATION REVIEW REQUEST The reason I think there has been a change since the last order is because (check all that apply): My income has changed. The income for the other parent has changed. It has been more than 3 years since my order has been changed. An order has been entered changing the custody, placement, or parenting time of the child(ren) on this case. There has been a change in the child care costs for the child(ren) on this case. There has been a change in the number of children I care for. There has been a change in the number of children the other party cares for. There has been a change in my health care coverage for the child(ren). There has been a change in the other parent222s health care coverage for the child(ren). I have been released from incarceration. The other party has been released from incarceration. PLEASE ATTACH ANY PAPERWORK THAT SUPPORTS THE BOXES YOU CHECKED ABOVE. By signing here, you are declaring that the information in this questionnaire and any attachments are true to the best of your information, knowledge, and belief. By signing here, you are requesting child support services pursuant to the child support enforcement program of Title IV-D of the Social Security Act. Signature **IF THERE IS NO SIGNATURE, WE CANNOT USE THIS INFORMATION** SIGN HERE 1 American LegalNet, Inc. www.FormsWorkFlow.com 1101 BEACH ST., FLINT, MI 48502 810.257.3300 PLAINTIFF: v. DEFENDANT: If you and the other party agree on what you want child support to be, or if you agree you don222t want child support and are not receiving public assistance, there is a faster process. For express service call 810.257.3300 and schedule an appointment with your caseworker to create a child support order that you and the other party can agree to. If you cannot agree, please fill out this form as soon as you can and return it to our office. MAIL TO: 1101 BEACH ST. QUESTIONS: 810.257.3300 FLINT, MI 48502 ASK FOR MODIFICATION UNIT PART ONE First, we need to verify who you are. Please answer the next few questions so we can be sure you are the person filling out the form. Your full name Your date of birth Address Home Phone Work Phone Cell Phone Social Security # E - mail Address Scars, Tattoos Driver222s License # Eye Color Hair Color Race Gender By signing here, you are declaring that the information in this questionnaire and any attachments are true to the best of your information, knowledge, and belief. By signing here, you are requesting child support services pursuant to the child support enforcement program of Title IV-D of the Social Security Act. Signature **IF THERE IS NO SIGNATURE, WE CANNOT USE THIS INFORMATION** PART TWO CHILDREN222S INFORMATION Now we need to gather some basic information about your children and your income so we can calculate support under the Michigan Child Support Formula. The more information you provide the better our calculation can be. Names of children in common with other parent on this case Birthdate SSN Anticipated Graduation Date Lives with (if not you or other parent on this case, provide name and address) Me Other parent Someone else Me Other parent Someone else 7 TH JUDICIAL CIRCUIT OF MICHIGAN GENESEE COUNTY FRIEND OF THE COU RT CHILD SUPPORT QUESTIONNAIRE CASE NUMBER EXPRESS SERVICE SIGN HERE 2 American LegalNet, Inc. www.FormsWorkFlow.com Me Other parent Someone else Me Other parent Someone else **If you have more children you cannot fit on this part of the form, attach a sheet of paper and list the same information about your other children.** Names of other biological or a dopted (or guardianship) minor children you support Birthdate Lives with (if not you or other parent on this case, provide name and address) Me Other parent Someone else Me Other parent Someone else **If you have more children you cannot fit on this part of the form or if you are currently pregnant, attach a sheet of paper and list the same information about your other children.** INCOME INFORMATION If you attach your four most recent paycheck stubs, a copy of your last federal tax returns, including all schedules, and your most recent W2 or 1099 you do not need to fill out the rest of PART TWO. If you cannot work because you are disabled, if you provide a copy of medical documentation or formal paperwork from the Social Security Administration that you are PERMANENTLY disabled, you do not fill out the rest of PART TWO. If you are not the parent of the child on this case, you do not need to fill out the rest of PART TWO. THIS BOX IS FOR IF YOU ARE CURRENTLY EMPLOYED Your occupation Your current employer Date Hired Employer222s Address Employer 222s Phone # Earnings before taxes $ Weekly Every two weeks Twice per month Monthly Hourly pay rate Avg hours worked per pay period Filing Status Married Single Head of Household Did Not File 226 Dependent222s Claimed Avg overtime hours worked for past 12 months Self Employed 226 Please provide 3 Years Tax Returns **IF YOU HAVE MORE THAN ONE JOB, ATTACH A SHEET OF PAPER WITH THE SAME INFORMATION ABOUT THE OTHER JOBS** THIS BOX IS FOR IF YOU ARE CURRENTLY UNEMPLOYED Name of last full time employer Position or job title at last employer Last day of employment Employer222s Address Employer222s Phone # Earnings before taxes $ Weekly Every two weeks Twice per month Monthly Hourly pay rate Avg hours worked per pay period Length of time employed in last full time position Reason for leaving last full time position PART THREE REQUIRED INFORMATION PURSUANT TO THE FORMULA OTHER INCOME, ASSETS, AND BENEFITS Commissions Unemp. Benefits Nat222l Guard & Res Drill Pay Bonuses Armed Services Allowance for Rent Pr ofit Sharing Sick Benefits Rental Income QUICK TIP 3 American LegalNet, Inc. www.FormsWorkFlow.com Dividends Worker222s Co mp State Disability Asst. Annuities Soc. Sec. Benefits VA Benefits Pens ions Disability Insurance SSI Trust Funds GI Benefits Other Alimony or Spousal Support involving another person not a parent to this case No Yes, as payer Yes, as recipient Case Number County, State Amount Case Number County, State Amount Do any of the children listed above receive payments from the Social Security Administration? Yes No Child222s Name Monthly Amount Type of Benefit Source of Dependent Benefit (mother, father, stepparent, self) SSI Dependent Benefit SSI Dependent Benefit PERSONAL HIS TORY What is your educational background? (Check all that apply) Less than high school High school graduate Trade school graduate (specify): Associate222s degree (specify): Bachelor222s degree (specify): Graduate degree (specify): Do you have any professional licenses? List: Are you able to work? Yes No If no, why? Please provide documentation Have you ever been convicted of a felony? Yes No If yes, what dates: PART FOUR MEDICAL COVERAGE How do you get your medical insurance? Employer Provided Medicaid/Medicare No Insurance Spouse Medical insurance company name, address, telephone #, policy number, beginning date Dental insurance company name, address, telephone #, policy number, b eginning date Optical insurance company name, address, telephone #, policy number, beginning date What dependent coverage is available to you without additional cost? Medical Dental Optical What dependent coverage is available you with additional cost? How much more than individual coverage? (Specify pay period) Medical per Denta l per Optical per Who do you, or your current spouse, cover on your insurance? Name Birthdate Relationship Type PART FIVE: VE