Free foc39e.pmd - Michigan

Approved, SCAO

Original - Friend of the court Additional copies as needed

STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY
Friend of the court address

CASE NO. CHILD-CARE VERIFICATION
Telephone no.

PARENT INFORMATION Complete the top portion of this form and have your child-care provider complete the remainder. It is your responsibility to return the completed form to the friend of the court.
Name

Name(s) and age(s) of child(ren) involved in this case

Are you receiving financial assistance for child care from any federal or state agency: If yes, please state the name of the agency and the amount your are receiving.

Yes

No

CHILD-CARE PROVIDER INFORMATION Please attach a schedule of your most recent child-care rates. The child-care provider must complete the remainder of this form for the child(ren) named above.
Name of provider Address

City

State

Zip

County

Area code and Telephone no. Total Weekly Rate

Name and Age of Child

School Year Rates

Average No. of Hours/Week Hourly Rate

Name and Age of Child

Summer Season Rates

Average No. of Hours/Week Hourly Rate

Total Weekly Rate

Do you require payment for services even when children are absent to guarantee a position in your center?

Yes

No

If yes, please explain.
Does a federal or state agency contribute all or a portion of these child-care services? If yes, please provide the agency name and amount contributed.

Yes

No

The information above is provided to enable the friend of the court to accurately report child-care costs in making a child-support recommendation. I certify that the information provided above is true, accurate, and complete.
Date FOC 39e (3/09) Signature and title of provider

CHILD-CARE VERIFICATION