Free foc55.pmd - Michigan

Approved, SCAO

Original - Friend of the court 1st copy - Requesting party as needed

2nd copy - Other party as needed 3rd copy - Court as needed

STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY
Friend of the Court address

CASE NO. STATEMENT OF ACCOUNT
Telephone no.

Plaintiff's name and address

v
Defendant's name and address

1. Name of payer: 2. Date of support order: 3. I certify that as of
Date

the overdue support and other obligations on the records of the Michigan

Child Support Enforcement System were:
Frequency of payment

Type of payment a. Child support b. Spousal support c. Fixed obligation d. Confinement/ Medical expenses e. Service fees f. Other

Charge amount

Overdue amount

Total 4. Last payment date: Last payment amount:

Date

Signature Name (type or print) Title

FOC 55 (3/09)

STATEMENT OF ACCOUNT

MCL 552.1601(1)(c)