Approved, SCAO
Original - Friend of the court Copies - All parties
STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY
DOMESTIC RELATIONS JUDGMENT INFORMATION, PAGE 1 TEMPORARY FINAL
CASE NO.
USE NOTE: Complete this form and file it with the friend of the court (do not file this form with the office of the clerk of the court) when the first temporary custody, parenting-time, or support order is entered and when submitting any final proposed judgment awarding custody, parenting time, or support. Mail a copy to each party and file proof of mailing with the court (may use form MC 302, Proof of Mailing).
(Check this box when information is being modified.)
Except as otherwise indicated below, all information previously provided is unchanged.
Date
Signature
Plaintiff Information
Name Address
Defendant Information
Name Address
Social security number
Telephone number
Social security number
Telephone number
Employer name, address, telephone number, and FEIN (if known)
Employer name, address, telephone number, and FEIN (if known)
Driver's license number and state Occupational license number(s), type(s), issuing state(s), and date(s)
Driver's license number and state Occupational license number(s), type(s), issuing state(s), and date(s)
CUSTODY PROVISIONS Child's name
sole, plaintiff = P sole, defendant = D
joint = J
other = O (must identify)
Social security Date of birth number
Physical custody
P, D, J, O
Child's primary residence address
Legal custody
P, D, J, O
SUPPORT PROVISIONS Support provisions are stated in the Uniform Support Order. Medical Support provisions are stated on page 2 of this form.
FOC 100 (3/09)
DOMESTIC RELATIONS JUDGMENT INFORMATION, PAGE 1
MCR 3.211(F)
Approved, SCAO
Original - Friend of the court Copies - All parties
STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY
DOMESTIC RELATIONS JUDGMENT INFORMATION, PAGE 2 TEMPORARY FINAL
CASE NO.
MEDICAL SUPPORT PROVISIONS: List the name of each insurance provider for the plaintiff and the defendant. Then enter the name of each child in this case who is covered by that provider and the type of coverage provided. Plaintiff's Insurance Coverage
Name and address of provider Policy no. Cert. no. Child(ren)'s name(s) Medical Dental Optical Other
Defendant's Insurance Coverage
Name and address of provider Policy no. Cert. no. Child(ren)'s name(s) Medical Dental Optical Other
FOC 100 (3/09)
DOMESTIC RELATIONS JUDGMENT INFORMATION, PAGE 2
MCR 3.211(F)