Approved, SCAO
STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY
Friend of the court address
EMPLOYER'S DISCLOSURE OF INCOME AND HEALTH INSURANCE INFORMATION
CASE NO.
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 contact (type or print) 1. Employee name 3. Social security number 6. Employer address 4. Employer name Title 2. Address 5. Employer federal identification no. Telephone no. Date
Complete items 7, 8, and 9 if insurance is available to employee.
7. Medical insurance company name, address, telephone no. Policy number 8. Dental insurance company name, address, telephone no. Policy number
9. Optical insurance company name, address, telephone no. Policy number 10. What dependent coverage is automatically available?
Medical
11. What dependent coverage is available by payment of an additional premium? Specify cost to employee
Dental
per individual
Optical
per family
Medical Name
per DOB
Dental Relationship
per Medical
Optical Dental
per Optical
12. What dependents of employee are covered?
Effective Date of Coverage
13. Hourly base pay 14. Shift premium 20. No. weeks paid this yr. 21. Date hired
15. COLA
16. Avg. overtime
17. W-4 Exemp. 18. Reg. work hours 19. Pay period (weekly, etc.)
$
/week
/week
24. Is this person receiving unemployment benefits?
22. Date of term. (if appl.) 23. Reason for leaving
Yes No
Calculate year to date figures as of last pay period.
25.
INCOME
Reg. Earnings (incl. shift prem. and COLA)
Overtime
Commissions and Bonuses
Pension and Longevity
Profit Sharing
Other (explain)
Gross
Deferred income in addition to gross
Year to Date Last Calendar Year
26.
OTHER INCOME Year to Date Last Calendar Year
27.
Disability
Workers Comp.
Sick Pay
SUB Pay
Disability carrier Worker's compensation carrier
WITHHOLDING
Federal Income Tax
F.I.C.A.
State Income Tax
Local Income Tax
Mandatory Professional or Union Dues
Alimony and Child Support
Mandatory Withholding (explain)
Year to Date Last Calendar Year
Sign and return to the friend of the court address listed above. Use other side if necessary. See the notice on the other side.
Date FOC 22 (3/08) Name and signature of person preparing form Telephone no.
EMPLOYER'S DISCLOSURE OF INCOME AND HEALTH INSURANCE INFORMATION
NOTICE TO EMPLOYER Pursuant to 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 former employer 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 employed as 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 shall be reported, regardless of the method of payment. (e) The following information concerning the person's current and former employment status: whether or not the custodial parent or absent parent is currently employed, laid off, or on sick, disability, or other leave of absence, or retired and the amount of income 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 the other side.