Free foc23.pmd - Michigan

Approved, SCAO

Original - Friend of the court 1st copy - Plaintiff/Attorney 2nd copy - Defendant/Attorney

STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY
1. Mother's last name 3. Date of birth First name

CASE NO. VERIFIED STATEMENT AND APPLICATION FOR IV-D SERVICES
Middle name 4. Social security number 2. Any other names by which mother is or has been known 5. Driver's license number and state

6. Mailing address and residence address (if different) 7. Eye color 8. Hair color 9. Height 10. Weight 11. Race 12. Scars, tattoos, etc. 16. Occupation 18. Gross weekly income

13. Home telephone no.

14. Work telephone no.

15. Maiden name

17. Business/Employer's name and address

19. Has mother applied for or does she receive public assistance? If yes, please specify kind. 20. DHS case number

Yes

No
First name Middle name 24. Social security number 22. Any other names by which father is or has been known 25. Driver's license number and state

21. Father's last name 23. Date of birth

26. Mailing address and residence address (if different) 27. Eye color 28. Hair color 29. Height 30. Weight 31. Race 35. Occupation 37. Gross weekly income 32. Scars, tattoos, etc.

33. Home telephone no.

34. Work telephone no.

36. Business/Employer's name and address

38. Has father applied for or does he receive public assistance? If yes, please specify kind. 39. DHS case number

Yes

No
b. Birth Date c. Age d. Soc. Sec. No. e. Residential Address

40. a. Name of Minor Child Involved in Case

41. a. Name of Other Minor Child of Either Party b. Birth Date

c. Age

d. Residential Address

42. Health care coverage available for each minor child a. Name of Minor Child b. Name of Policy Holder c. Name of Insurance Co./HMO d. Policy/Certificate/Contract No.

43. Names and addresses of person(s) other than parties, if any, who may have custody of child(ren) during pendency of this case

If any of the public assistance information above changes before your judgment is entered, you are required to give the friend of the court written notice of the change. I request support services under Title IV-D of the Social Security Act. I declare that the statements above are true to the best of my information, knowledge, and belief.
Date FOC 23 (3/08) Signature

VERIFIED STATEMENT AND APPLICATION FOR IV-D SERVICES

MCR 3.206(B)