CASE NO. (MUST BE PROVIDED) STATE OF MICHIGAN COUNTY OF WAYNE THIRD JUDICIAL CIRCUIT COURT FAMILY DIVISION FINANCIAL INFORMATION FORM (SSN IF CASE NO. IS NOT KNOWN) PLEASE COMPLETE BOTH PLAINTIFF AND DEFENDANT INFORMATION COLUMNS TO THE BEST OF YOUR ABILITY Plaintiff Defendant REQUESTED BY: FOR: PLAINTIFF Name Address City/State/Zip Employer Address City/State/Zip Occupation Social Security Number Gross Weekly Income ** $ Other Income (rental, stocks, etc.) +$ Total Gross Income =$ Other Child Support Paid on Account Number(s) Increase Decrease DEFENDANT Name Address City/State/Zip Employer Address City/State/Zip Occupation Social Security Number Gross Weekly Income ** $ Other Income (rental, stocks, etc.) +$ Total Gross Income =$ Other Child Support Paid on Account Number(s) $ $ Presently Married Yes No Date Married Names and dates of birth of your natural children not included in this case: $ $ Presently Married Yes No Date Married Names and dates of birth of your natural children not included in this case: HOW MUCH CHILD SUPPORT ARE YOU REQUESTING/OFFERING $ PER WEEK PER CHILD. ADDITIONAL STATEMENTS MAY BE MADE ON A SEPARATE SHEET I authorize my employer to release my payroll information. I make application to the Wayne County Friend of the Court for continuing child support services under the provisions of the Child Support Enforcement Program as required under Title-IV. I acknowledge receipt of the Notice of Hearing and Motion to Change Support Order, and I hereby submit myself to the jurisdiction of the Court. I declare that the statements above are true to the best of my information, knowledge, and belief. DATE SIGNATURE ** PLEASE ATTACH PROOF OF YOUR INCOME FOR THE LAST 6 MONTHS (e.g., paystubs, W-2, tax return, letter) plus any additional statements PAYMENT INFORMATION REGARDING YOUR ACCOUNT IS AVAILABLE 24 HOURS PER DAY AT (313) 224-5300 FD/FOC4008 (Rev. 6/02) FINANCIAL INFORMATION FORM American LegalNet, Inc. www.FormsWorkflow.com