Free foc21.pmd - Michigan

Approved, SCAO

Original - Court 1st copy - Friend of the court 2nd copy - Employer

STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY
Court address

MOTION AND ORDER FOR DISCLOSURE OF INCOME AND HEALTH INSURANCE INFORMATION

CASE NO.

Telephone no.

Plaintiff's name, address, and telephone no.

v

Defendant's name, address, and telephone no.

TO:

Source of income PERSONNEL DEPARTMENT: CONFIDENTIAL

MOTION 1. Pursuant to statute, the friend of the court is conducting an investigation. Disclosure of income and available health insurance coverage is essential to the completion of the investigation. 2. income named above. 3. THE FRIEND OF THE COURT REQUESTS that the court order the source of income to disclose all wages, earnings, salaries, commissions, or other income, and all medical, dental, hospitalization, optical, or other health-related insurance coverage available to the income recipient.
Date Friend of the court

is employed by or receives income from the source of

ORDER 1. Date of hearing: Judge:
Bar no.

2. IT IS ORDERED that the motion for disclosure of income and health insurance information is granted, and the source of income named above shall make immediate and full disclosure as required by the friend of the court.
Judge

CERTIFICATE OF MAILING I certify that on this date I served a copy of this motion and order to the source of income by first-class mail addressed to the lastknown address as defined in MCR 3.203.
Date FOC 21 (3/09) Signature MCL 552.505, MCL 552.517

MOTION AND ORDER FOR DISCLOSURE OF INCOME AND HEALTH INSURANCE INFORMATION