COPY REQUEST FORM CASE NUMBER______________________________ MAN'S NAME _______________________________ CASEWORKER ______________________________ S.S. NO. _____________________________________ BIRTHDATE ________________________________ WOMAN'S NAME ____________________________ S.S. NO. _____________________________________ BIRTHDATE ________________________________ CHILD(REN) 'S NAME (S): ______________________________________ S.S. NO. ___________________________ D.O.B. _________________ ______________________________________ S.S. NO. ___________________________ D.O.B. _________________ ______________________________________ S.S. NO. ___________________________ D.O.B. _________________ ______________________________________ S.S. NO. ___________________________ D.O.B. _________________ I hereby request a copy of the following records contained in my file: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ I understand that I must pay to the Genesee County Treasurer, on Account Number 215-1420-24985, the costs of reproduction ($1.00 per page, per copy, plus postage) and present the receipt to the Friend of the Court before copies will be made and mailed to me. REQUESTED BY: ____________________________________ SIGNATURE DATED: _____________________________________________ __________________________________ DRIVER LICENSE NO. AND STATE CURRENT ADDRESS: ___________________________________________ COST OF COPIES: ________________ POSTAGE: TOTAL COST: ________________ ________________ ________________ ________________ ___________________________________________ RECEIPT NO.: ___________________________________________ AMOUNT: TELEPHONE NUMBER (8 A.M. TO 5 P.M.) ___________________________________________ COPIES MADE BY: _______________ American LegalNet, Inc. www.FormsWorkFlow.com