Free foc22b.pmd - Michigan

Approved, SCAO

STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY
Friend of the court address

CASE NO. EMPLOYMENT STATUS DISCLOSURE
Fax number 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.
Contact person Title Telephone no. Date

Employer name and address

Name of individual

ATTENTION:

Social security number

Our records indicate that you are the last-known employer for the individual stated above. This information may no longer be accurate. Our office may have previously issued an income withholding notice for this individual to your company. If you received a notice, please note that MCL 552.611 through MCL 552.614 require you to honor the notice. Please contact the friend of the court by completing, signing, and returning this form within 7 days of receipt by mail or facsimile at the above address or Fax number. Thank you for your cooperation; your assistance is appreciated. The individual is currently employed here and has been since
Date

.

If the individual is not employed with you, please check the items below that apply. The individual was never employed here. The individual quit was fired was terminated was laid off on
Date

.

The individual is receiving unemployment from:
Name Address

(
City, state, zip

)
Telephone no.

The individual is receiving benefits from:
Name

Workers' compensation Disability

Address

(
City, state, zip

)
Telephone no.

The individual may now be working at:
Name Address

(
City, state, zip

)
Telephone no.

The last-known address of the individual is:
Address

(
City, state, zip

)
Telephone no.

Date

Name of person preparing form (type or print)

Signature of person preparing form

(
FOC 22b (3/08)

)

EMPLOYMENT STATUS DISCLOSURE

Telephone no.