Oakland County Friend of the Court 230 ELIZABETH LAKE ROAD PETER K. DEVER SUZANNE HOLLYER PONTIAC, MI 48341-1011 FRIEND OF THE COURT MAILING ADDRESS: P.O.BOX 436012 CLAUDIA MARTELLO PAMELA J. SALA PONTIAC, MI 48343-6012 TELEPHONE: (248) 858-0424 website: www.oakgov.com/foc CHIEF ASSISTANTS FAX: (248) 858-0461 AFFIDAVIT OF HEALTH CARE EXPENSES __________________________________ Name __________________________________ Case number I ______________________________________swear that health care expenses (print your name here) incurred on behalf of the minor child(ren) have exceeded $289.00 per child, which is the annual amount designated as “ordinary health care expenses”. I have presented copies of these expenses to the other party on this case. I swear under penalties of perjury that this information is true, accurate, and complete to the best of my information, knowledge and belief. _______________ ____________________________________ Date Signature PLEASE USE THE TABLE ON THE NEXT PAGE TO LIST THE HEALTH CARE EXPENSES UP TO THE ANNUAL ORDINARY HEALTH CARE EXPENSE AMOUNT. THEN USE THE ENCLOSED REQUEST FOR HEALTH CARE EXPENSE PAYMENT FORM TO LIST EXPENSES WHICH HAVE EXCEEDED THE ANNUAL ORDINARY HEALTH CARE EXPENSE AMOUNT. SEND THIS AFFIDAVIT WITH THE COMPLETED REQUEST FORM TO THE FRIEND OF THE COURT. American LegalNet, Inc. www.FormsWorkflow.com Please use the table below to list the current year health care expenses up to the first $289 per child: Child receiving service Health care provider Date of service Type of service Cost of service Amount paid by insurance Out-of-pocket cost Grand total: $_________ American LegalNet, Inc. www.FormsWorkflow.com