Approved, SCAO
JIS CODE: RFF
STATE OF MICHIGAN
JUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY
REQUEST FOR FINANCIAL INFORMATION
CASE NO. PETITION NO.
TO WHOM IT MAY CONCERN:
I authorize my employers, creditors, and others who may have knowledge of my financial affairs to release information to the above court. A photocopy of this authorization shall suffice as an original.
Date
Signature Signature
Please send information on the items checked below regarding:
Name
DOB
Soc. sec. no. or employee/badge no.
EMPLOYMENT INFORMATION (or subsidy)
EARNINGS Hourly Wage ................................................................ Average regular hours worked per week Weekly straight-time pay Average overtime pay per week Salary ................................................ OTHER COMPENSATION $ $ $ $
Hire date DEDUCTIONS (other than taxes) Union dues ( check if required) Insurance ( check if required)
Number of dependents claimed
$ X $ $ per per per per
$ $ $ $ $ $
per per per per per per
0
Credit union
$ per OTHER (Pension, deferred compensation, stock plan, etc.)
FINANCIAL INFORMATION
ASSETS (checking, savings, stocks, bonds, IRAs, etc.)
To be completed by banks, savings and loans, credit unions, loan companies, brokerage firms, etc. LOANS Balance/Value Payment Balance $ Real Estate: $ $ per $ Original loan Motor $ Vehicle: $ per $
Make and year
$ $ $
$ $ $
per per per
$ $ $
Date
Signature
Title
PLEASE RETURN THE ABOVE INFORMATION BY TO THE ADDRESS AT LEFT.
Date
THANK YOU.
JC 37 (9/07)
REQUEST FOR FINANCIAL INFORMATION