Free foc39.pmd - Michigan

Approved, SCAO

STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY
Friend of the court address

CASE NO. FRIEND OF THE COURT CASE QUESTIONNAIRE (Page 1)
Telephone no.

Plaintiff

v

Defendant

Complete this form and sign on page 4. YOUR GENERAL INFORMATION
1. Your full name City 8. Driver's license no. 14. Hair color 2. Date of birth State Zip 3. Place of birth: city and state 5. Home telephone 10. Cell phone 6. Work telephone 11. E-mail address

4. Address 7. Social security number 13. Eye color

9. Professional license, type, and no. 15. Height 16. Weight

12. Sex

17. Race

18. Scars, tattoos, etc.

M

F
20. Your mother's full maiden name Gender Soc. sec. no. Address
No. of overnights you have w/ child annually

19. Your father's full name

21. Names of children in common with other parent in this case Birthdate

22. Names of all additional minor children you support

Birthdate

Address

23. Are you pregnant? a. When is the child due? b. Is the other party in this case the biological parent of the expected child? 24. Are you presently married? Yes No Yes No Yes No

YOUR INCOME, MEDICAL, EDUCATIONAL, AND HEALTH INSURANCE INFORMATION
25. Your occupation 27. Employer's address City 26. Your employer (if unemployed, name of last employer) State Zip 28. Date hired

29. Gross earnings per pay period (earnings before taxes) 30. Filing status ________ dependents claimed $ weekly biweekly bimonthly monthly 31. Hourly pay rate (including shift premium 32. Total regular hours worked per pay period 33. Average overtime hours for past 12 and COLA) months 34. Second job 35. Employer 36. Employer's address City State Zip 37. Date hired

38. Gross earnings per pay period (earnings before taxes) 39. Hourly pay rate 40. Average hours worked per $ pay period since hire date weekly biweekly bimonthly monthly 41. If unemployed and not receiving unemployment or worker's compensation benefits, or working part-time only, provide the following information: Name of last full-time employer Position held at last place of full-time employment Length of time employed in last full-time position Gross earnings per pay period (earnings before taxes) $ weekly biweekly FOC 39 (3/09) Address of last full-time employer Last day employed full-time Reason for leaving last full-time employment

bimonthly

monthly

FRIEND OF THE COURT - CASE QUESTIONNAIRE (Page 1)

Approved, SCAO

STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY

FRIEND OF THE COURT CASE QUESTIONNAIRE (Page 2)

CASE NO.

YOUR INCOME, MEDICAL, EDUCATIONAL, AND HEALTH INSURANCE INFORMATION (continued)
42. List MONTHLY income from all other sources, such as: Commissions Unemp. Benefits Nat'l. Guard & Res. Drill Pay Bonuses Strike Pay Armed Services Profit Sharing SUB Pay Allowance for Rent Interest Sick Benefits Rental Income Dividends Worker's Comp. Spousal Support/Alimony Annuities Soc. Sec. Benefits State Disability Assistance Pensions/Longevity VA Benefits FIP Deferred Comp./IRA Disability Insurance Supp. Security Income SSI Trust Funds GI Benefits Other 43. Do you have any alimony orders involving another person not a parent in this case? If so, complete a. b. and c. No Yes, as payer Yes, as recipient a. Amount of order (do not include arrearages) b. Type of order/Case no. c. City, county, and state

44. Do any of the children listed on item 21 and 22 receive payments from the Social Security Administration? Child's Name Amount (monthly) Type of benefit (check one) SSI Dependent benefit

Yes

No

Source of dependent benefit (mother, father, stepparent)

45. Attach your four most recent paycheck stubs, or a statement from your employer(s) of wages and deductions, and year-to-date earnings, and a copy of your last federal and state income tax returns, including all schedules. If self-employed, also attach a copy of your three most recent business tax returns and/or corporation returns. 46. Do you have any medical conditions/restrictions that affect your ability to work? If yes, please explain medical condition/restriction: Yes No 47. What is your educational background? (Check one) Less than high school High school graduate Associate's degree Bachelor's degree 48. Medical insurance company name, address, telephone no. 49. Dental insurance company name, address, telephone no. 50. Optical insurance company name, address, telephone no. 51. What dependent coverage is available to you without cost? Medical Dental Optical 52. What dependent coverage is available by payment of an additional premium? (Specify cost per pay period.) Medical per Dental per Optical 53. Individuals currently covered by your insurance Name Birthdate Relationship Medical ( )

Trade school graduate Graduate degree Policy number Beginning date, if known Policy number Policy number Beginning date, if known Beginning date, if known

per Dental ( ) Optical ( )

FOC 39 (3/09)

FRIEND OF THE COURT - CASE QUESTIONNAIRE (Page 2)

Approved, SCAO

STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY YOUR CHILD-CARE INFORMATION

FRIEND OF THE COURT CASE QUESTIONNAIRE (Page 3)

CASE NO.

54. Do you have child-care expenses for the minor children in this domestic relations case during any time of the year? If yes, complete the following information. Name of child-care provider Names of children receiving child care Number of weeks provided during last calendar year Current weekly child-care cost

Yes

No

Estimated number of weeks of child care provided in this calendar year

Amount of child-care credit received on last year's federal I.R.S. tax return

55. Check the reason(s) which explain why you need child care and estimate the number of hours child care is received for each. Reason Estimated number of hours per week Work related Looking for employment Enrolled in educational program to improve employment opportunities 56. If your reason for child care is education related, provide the following information. Name of educational institution Total classroom hours per week Educational goal

Projected graduation date

YOUR ADDITIONAL INFORMATION
57. List any additional information that would be useful to the court in making a support recommendation.

INFORMATION REGARDING THE OTHER PARENT IN THIS CASE (if known)
58. Full name 61. Address 64. Social security number 69. Sex 70. Eye color City State 59. Date of birth Zip 62. 60. Place of birth: city and state Home telephone 63. Work telephone 68. E-mail address

65. Driver's license number 71. Hair color

66. Professional license, type, and no. 67. Cell phone 73. Weight 74. Race

72. Height

75. Scars, tattoos, etc.

M

F
77. Mother's full maiden name Birthdate Address

76. Father's full name 78. Names of all additional minor children he/she supports

79. Is this party pregnant? Yes 81. Occupation No

a. When is the child due?

b. Is the party in this case the biological parent of the expected child? Yes No 82. Employer (if unemployed, name of last employer)

80. Is this parent married? Yes No

83. Employer's address

City

State

Zip

84. Date hired

85. Gross earnings per pay period (earnings before taxes)

86. Average overtime hours for past 12 months

FOC 39 (3/09)

FRIEND OF THE COURT - CASE QUESTIONNAIRE (Page 3)

Approved, SCAO

STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY

FRIEND OF THE COURT CASE QUESTIONNAIRE (Page 4)

CASE NO.

INFORMATION REGARDING THE OTHER PARENT IN THIS CASE (continued)
87. Medical insurance company name, address, telephone no. 88. Dental insurance company name, address, telephone no. 89. Optical insurance company name, address, telephone no. 90. What dependent coverage is available to the other parent without cost? Medical Dental 91. What dependent coverage is available by payment of an additional premium? (Specify cost per pay period.) Medical per Dental 92. Individuals currently covered by other parent's insurance Name Birthdate per Relationship Optical Medical ( ) Optical per Dental ( ) Optical ( ) Policy number Policy number Policy number Beginning date, if known Beginning date, if known Beginning date, if known

If you want friend of the court services, you must check the box below. I request child-support services pursuant to the child-support enforcement program of Title IV-D of the Social Security Act.

Date

Signature

Reminder List

· · · · · · ·

Have you signed this questionnaire? Have you attached your four most recent paycheck stubs, or a statement from your employer(s) of wages and deductions and year-to-date earnings? Have you attached a copy of your last federal and state income tax returns, including all schedules, W-2s, and 1099s? If self-employed, also attach a copy of your three most recent business tax returns and/or corporation returns. Attach any additional information that may be useful to the friend of the court in making a support recommendation. Make sure you use enough postage to cover these additional items. Have you attached the Child Care Verification (form FOC 39e) if you are asking for reimbursement of child-care expenses? Make a copy of this form for your own records. Send the original form, completed and signed, to the friend of the court office.

FOC 39 (3/09)

FRIEND OF THE COURT - CASE QUESTIONNAIRE (Page 4)