MONROE COUNTY FRIEND OF THE COURT ADDRESS/EMPLOYMENT/INSURANCE UPDATE YOUR (NEW) NAME ________________________________CASE NO. _______________-D___ YOUR ADDRESS/APT./TRAILER #___________________________________________________ CITY/STATE/ZIP ________________, _____ TELEPHONE ( )____________________ _____________ DATE OF BIRTH _________ SOCIAL SECURITY NO.______________________ DRIVERS LIC. #___________________ OCCUPATIONAL LIC./AGENCY ___________________ HEIGHT _________ WEIGHT ________ EYE COLOR ________ HAIR ________ RACE ______ SCARS, TATOOS, ETC. __________________________________________________________ YOUR EMPLOYER'S NAME _________________________________________________________ EMPLOYER ADDRESS/CITY/STATE/ZIP ______________________________________________ EMPLOYER TELEPHONE ( )______________ EXT. ______ DATE OF HIRE _____________ RATE OF PAY ______ PER _______ SUPERVISOR ____________________________________ HEALTH INS. _____________________________POLICY # ____________________________ DENTAL INS. ___________________________________POLICY # ______________________ OPTICAL INS. __________________________________ POLICY # _____________________ OTHER INS. ____________________________________ POLICY # _____________________ OTHER PARTY'S NAME ___________________________________________________________ DATE ___________ SIGNATURE _________________________________ Subscribed and sworn to before me, a notary public in and for Monroe County this _________ day of __________, 200___. ______________________________________ Notary Public, Monroe County, Michigan My commission expires ________________ MUST BE COMPLETELY FILLED OUT LOCAL FOC 901 (1/97) ADDRESS/EMPLOYMENT/INSURANCE UPDATE FORM (EMPAFF.DOC) American LegalNet, Inc. www.FormsWorkflow.com