Approved, SCAO STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY Friend of the court address CASE NO. FRIEND OF THE COURT CASE QUESTIONNAIRE (Page 1) Telephone no. Plaintiff v Defendant Complete this form and sign on page 4. YOUR GENERAL INFORMATION 1. Your full name City 8. Driver's license no. 14. Hair color 2. Date of birth State Zip 3. Place of birth: city and state 5. Home telephone 10. Cell phone 6. Work telephone 11. E-mail address 4. Address 7. Social security number 13. Eye color 9. Professional license, type, and no. 15. Height 16. Weight 12. Sex 17. Race 18. Scars, tattoos, etc. M F 20. Your mother's full maiden name Birthdate Gender Soc. sec. no. Address No. of overnights you have w/ child annually 19. Your father's full name 21. Names of children in common with other parent in this case 22. Names of all additional minor children you support Birthdate Address 23. Are you pregnant? a. When is the child due? b. Is the other party in this case the biological parent of the expected child? 24. Are you presently married? Yes No Yes No Yes No YOUR INCOME, MEDICAL, EDUCATIONAL, AND HEALTH INSURANCE INFORMATION 25. Your occupation 27. Employer's address City 26. Your employer (if unemployed, name of last employer) State Zip 28. Date hired ________ dependents claimed 29. Gross earnings per pay period (earnings before taxes) weekly biweekly bimonthly monthly $ 31. Hourly pay rate (including shift premium 32. Total regular hours worked per pay period and COLA) 34. Second job 35. Employer 36. Employer's address City State 30. Filing status married single head of household 33. Average overtime hours for past 12 months Zip 37. Date hired 38. Gross earnings per pay period (earnings before taxes) 39. Hourly pay rate 40. Average hours worked per $ weekly biweekly bimonthly monthly pay period since hire date 41. If unemployed and not receiving unemployment or worker's compensation benefits, or working part-time only, provide the following information: Name of last full-time employer Position held at last place of full-time employment Length of time employed in last full-time position Gross earnings per pay period (earnings before taxes) $ weekly biweekly FOC 39 (3/14) Address of last full-time employer Last day employed full-time Reason for leaving last full-time employment bimonthly monthly American LegalNet, Inc. www.FormsWorkFlow.com FRIEND OF THE COURT - CASE QUESTIONNAIRE (Page 1) Approved, SCAO STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY FRIEND OF THE COURT CASE QUESTIONNAIRE (Page 2) CASE NO. YOUR INCOME, MEDICAL, EDUCATIONAL, AND HEALTH INSURANCE INFORMATION (continued) 42. List MONTHLY income from all other sources, such as: Commissions Unemp. Benefits Nat'l. Guard & Res. Drill Pay Bonuses Strike Pay Armed Services Profit Sharing SUB Pay Allowance for Rent Interest Sick Benefits Rental Income Dividends Worker's Comp. Spousal Support/Alimony Annuities Soc. Sec. Benefits State Disability Assistance Pensions/Longevity VA Benefits FIP Deferred Comp./IRA Disability Insurance Supp. Security Income SSI Trust Funds GI Benefits Other 43. Do you have any spousal support/alimony orders involving another person not a parent in this case? No Yes, as payer Yes, as recipient If so, complete a. b. and c. a. Amount of order (do not include arrearages) b. Type of order/Case no. c. City, county, and state 44. Do any of the children listed on item 21 and 22 receive payments from the Social Security Administration? Child's Name Amount (monthly) Type of benefit (check one) SSI Dependent benefit Yes No Source of dependent benefit (mother, father, stepparent) 45. Attach your four most recent paycheck stubs, or a statement from your employer(s) of wages and deductions, and year-to-date earnings, and a copy of your last federal and state income tax returns, including all schedules. If self-employed, also attach a copy of your three most recent business tax returns and/or corporation returns. 46. Do you have any medical conditions/restrictions that affect your ability to work? If yes, please explain medical condition/restriction: Yes No 47. What is your educational background? (Check one) Less than high school High school graduate Associate's degree Bachelor's degree 48. Medical insurance company name, address, telephone no. 49. Dental insurance company name, address, telephone no. 50. Optical insurance company name, address, telephone no. 51. What dependent coverage is available to you without cost? Trade school graduate Graduate degree Policy/Group number Beginning date, if known Policy/Group number Policy/Group number Beginning date, if known Beginning date, if known Medical Medical Name per Dental Birthdate per Dental Optical Optical per 52. What dependent coverage is available by payment of an additional premium? (Specify cost per pay period.) 53. Individuals currently covered by your insurance Relationship Medical () Dental () Optical () FOC 39 (3/14) FRIEND OF THE COURT - CASE QUESTIONNAIRE (Page 2) American LegalNet, Inc. www.FormsWorkFlow.com Approved, SCAO STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY YOUR CHILD-CARE INFORMATION FRIEND OF THE COURT CASE QUESTIONNAIRE (Page 3) CASE NO. 54. Do you have child-care expenses for the minor children in this domestic relations case during any time of the year? If yes, complete the following information. Name of child-care provider Names of children receiving child care Number of weeks provided during last calendar year Current weekly child-care cost Yes No Estimated number of weeks of child care provided in this calendar year Amount of child-care credit received on last year's federal I.R.S. tax return Does a federal or state agency or a public or private entity contribute all or a portion of the cost of child-care services? If yes, please explain. 55. Check the reason(s) which explain why you need child care and estimate the number of hours child care is received for each. Reason Estimated number of hours per week Work related Looking for employment Enrolled in educational program to improve employment opportunities 56. If your reason for child care is education related, provide the following information. Name of educational institution Total classroom hours per week Educational goal Projected graduation date YOUR ADDITIONAL INFORMATION 57. List any additional information that would be useful to the court in making a support recommendation. INFORMATION REGARDING THE OTHER PARENT IN THIS CASE (if known) 58. Full name 61. Address 64. Social security number 69. Se