Free foc22a.pmd - Michigan

Approved, SCAO

STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY
Friend of the court address

EMPLOYER'S DISCLOSURE OF HEALTH INSURANCE INFORMATION

COURT 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 FOC employee (type or print) 1. Employee name 3. Social security number 6. Employer address 4. Employer name Title 2. Address 5. Employer federal identification no. 7. IV-D case no. Telephone no. Date

Complete items 8, 9, and 10 if insurance is available to employee.
8. Medical insurance company name, address, telephone no. Policy number 9. Dental insurance company name, address, telephone no. Policy number

10. Optical insurance company name, address, telephone no. Policy number 11. What dependent coverage is automatically available?

Medical
12. 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

13. What dependents of employee are covered?

Effective Date of Coverage

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 22a (3/08) Name and signature of person preparing form Telephone no.

EMPLOYER'S DISCLOSURE OF 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.