STATEMENT AND/OR INFORMATION REQUEST GENESEE COUNTY FRIEND OF THE COURT YOUR NAME: _________________________________ YOUR S.S. # _________________________ CASE NUMBER: _____________________________ DATE OF BIRTH: ____________________________ ADDRESS:__________________________________________CITY: _________________STATE: _________ ZIP_____________ YOUR PHONE # _________________________________NAME OF OTHER PARTY:____________________________________ Please indicate below the reason pay records prior to 2003 are needed: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ _______________________________________ _________ ________________________________________________ SIGNATURE DATE DRIVER LICENSE NO. AND STATE -------------------------------------------------------------------------------------------OFFICE USE ONLY _________________________________________________ Form Prepared/Accepted By Date _________________________________________ Approved by: Date American LegalNet, Inc. www.FormsWorkFlow.com