Child Care Verification Form. This is a Michigan form and can be use in Oakland Local County.
Tags: Child Care Verification, Michigan Local County, Oakland
FRIEND OF THE COURT CASE QUESTIONNAIRE STATE OF MICHIGAN SIXTH JUDICIAL CIRCUIT OAKLAND COUNTY CASE NO. PAGE 1 FRIEND OF THE COURT P.O. BOX 436012 PONTIAC MI 48343 TELEPHONE NUMBER (248)858-0424 Plaintiff name Defendant name 1. Your full name 2. Date of birth 3. Place of birth: city & state 4. Mailing address and residence address (if different) 5. Sex M 6. Eye color 7. Hair color 8. Height 9. Weight 10. Race 11. Scars, tattoos, etc. F 12. Home telephone number 13. Father's full name 14. Work telephone number 15. Mother's full maiden name 16. Names of all your dependant children Birth date Social Security No. 17. Are you or the other parent in this case pregnant? Yes A. When is the child due? No Address Natural/step/adopted If yes, complete sections A and B below. B. Are the parties in this case the biological of the expected child? INFORMATION REGARDING THE OTHER PARENT IN THIS CASE (IF KNOWN) 18. Full name 19. Date of birth 20. Place of birth: city & state 21. Mailing address and residence address (if different) 22. Social Security No. 23. Driver's License No. 24. Home telephone 25. Work telephone 26. Sex M F 27. Eye color 28.Hair color 29. Height 33. Father's full name 16. Names of all your dependant children Is the other parent in this case married? 30. Weight 31. Race 32. Scars, tattoos, etc. 34. Mother's full maiden name Birth date Yes Social Security No. Address Natural/step/adopted No 2001 © American LegalNet, Inc. STATE OF MICHIGAN SIXTH JUDICIAL CIRCUIT OAKLAND COUNTY CASE NO. FRIEND OF THE COURT CASE QUESTIONNAIRE PAGE 2 CHECK YOUR INCOME TAX FILING STATUS: MARRIED SINGLE HEAD OF HOUSEHOLD NO. OF DEPENDANTS CLAIMED: INCOME INFORMATION 36. Your occupation 37. Your employer (if unemployed, name of last employer) 38. Employer's address City State 40. Gross earnings per pay period (earnings before taxes) $ Weekly Bi-weekly 42. Hourly pay rate $ Zip 39. Date hired 41. Social Security No. Bi-monthly Monthly 43. Total regular hours worked per pay period 44. Average overtime (including shift premium & COLA) hours for past 12 months 45. Second job 47. Employer's address 46. Employer City State 49. Gross earnings per pay period (earnings before taxes) $ Weekly Bi-weekly 50. Hourly pay rate $ Zip Bi-monthly 48. Date hired Monthly 51. Total regular hours worked per pay period (including shift premium & COLA) 52. List MONTHLY income from all other sources, such as: ______________________________ Commissions ______________________________ Bonuses ______________________________ Profit Sharing ______________________________ Interest ______________________________ Dividends ______________________________ Annuities ______________________________ Pensions/Longevity ______________________________ Deferred Compensation/IRA ______________________________ Trust Funds ______________________________ Unemployment Benefits ______________________________ Strike Pay ______________________________ SUB Pay ______________________________ Sick Benefits ______________________________ Worker's Compensation 53. Do you have any other alimony or child support orders? If yes, complete sections 53 A, B & C below A. Amount of order $ (do not include arrearages) ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ __________________ Social Security Benefits Supplemental Security Income (SSI) V.A. Benefits Disability Insurance G.I. Benefits National Guard & Reserve Drill Pay Armed Services Allowance for Rent Rental Income Spousal Support/Alimony General Assistance AFDC Other: ____________________ Other: ____________________ Yes, as payor B. Type of order/case no. Yes, as recipient No C. City, County & State 54. Do you provide the sole support for stepchildren residing in your home because support is unavailable from both natural/adoptive parents? Yes No If yes, how many stepchildren do you support? ____________________ If yes, state the reason the step children's mother is unable to provide support: If yes, State the reason the step children's father is unable to provide support: 55. Do any of the children listed on item 18 receive payments from the Social Security Administration? Child's name Amount (Monthly) Type of benefit SSI Dependent Benefit Yes No Source of dependent benefit (Mother, father, stepparent) 56. ATTACH YOUR 4 MOST RECENT PAYCHECKS STUBS, ON 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 3 MOST RECENT BUSINESS TAX RETURNS ANS/OR CORPORATION RETURNS. 2001 © American LegalNet, Inc. CASE NO. FRIEND OF THE COURT CASE QUESTIONNAIRE PAGE 3 STATE OF MICHIGAN SIXTH JUDICIAL CIRCUIT OAKLAND COUNTY INCOME INFORMATION OF OTHER PARENT IN THIS CASE (IF KNOWN) 56. Occupation 57. Employer (if unemployed, name of last employer) 58. Employer's address City State Zip 59. Hourly pay rate $ (including shift premium & COLA) 60. Gross earnings per pay period (earnings before taxes) $ Weekly Bi-weekly 61. Average overtime hours for past 12 months Bi-monthly Monthly HEALTH CARE INFORMATION 62. Medical insurance company name Policy no. Beginning date, if known 63. Dental insurance company name Policy no. Beginning date, if known 64. Optical insurance company name Policy no. Beginning date, if known 65. What dependent coverage is available by payment of an additional premium? (Specify cost per pay period): Medical $ Dental $ Optical $ 66. Individuals currently covered by your insurance: Name Birth date Relationship Medical Dental Optical CHILD CARE INFORMATION 67. 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: Yes No Name of child care provider Names of children receiving child care No. of weeks provided during last calendar year Estimated no. of weeks of child care provided in this calendar year Current weekly child care cost Amount of child care credit received on last year's federal IRS return 68. Check the reason(s) which explain why you need childcare and estimate the number of hours childcare is received for each. Reason Estimated number of hours per week Work related _______________________________________________________ Looking for Employment _______________________________________________________ Enrolled in educational program to improve employment opportunities _______________________________________________________ 69. If your reason for child care is educational related, provide the following information: Name of educational institution Total classroom hours per week Educational goal Projected graduation date 2001 © American LegalNet, Inc. FRIEND OF THE COURT CASE QUESTIONNAIRE STATE OF MICHIGAN SIXTH JUDICIAL CIRCUIT OAKLAND COUNTY CASE NO. PAGE 4 INFORMATION FOR LESS THAN FULL-TIME EMPLOYMENT 70. If unemployed and not receiving unemployment or worker's compensation benefits, or working part-time only, provide the following the following information: Name of last full-time employer Address of last full-time employer Position held at last full-time position Last day employed full-time Length of time employed in last full-time employment position Reason for leaving last full-time position Gross earnings per pay period at last place of full-time employment (earnings before taxes) $ Weekly Bi-weekly Bi-monthly Monthly 71. Do you have any medical conditions/restrictions that affect your ability to work? Yes No If yes, please explain medical conditions/restrictions: _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ 72. What is your educational background? (Check one) Less than high school Trade school graduate Bachelor's degree High school graduate Associates degree Graduate degree I hereby request child support services under the child support enforcement program of tittle IV-D of the Social Security Act. I understand that any information provided to me or on my behalf is to be used only for the purpose of establishing paternity or securing child support. I declare that the information in this questionnaire is true to the best of my information, knowledge, and belief. Date Signature Reminder List: Have you signed this questionnaire? Have you attached your 4 most recent paycheck stubs, or a statement from your employer(s) of wages and deductions and year-to-date earnings? Have you attached a copy of your last federal and state income tax returns, including all schedules? If self-employed, also attach a copy of your 3 most recent business tax returns and/or corporation returns. Attach any additional information that may be useful to the Friend of the Court in making a support recommendation. If you have not supplied all of the requested information, state the reasons for the omissions. Retain a copy of this form for your records. Return the original to the Friend of the Court office. 2001 © American LegalNet, Inc. CHILD CARE VERIFICATION STATE OF MICHIGAN SIXTH JUDICIAL CIRCUIT OAKLAND COUNTY CASE NO. FRIEND OF THE COURT P.O. BOX 436012 PONTIAC MI 48343 (248) 858-0424 PARENT INFORMATION COMPLETE THE TOP PORTION OF THIS FORM AND HAVE YOUR CHILDCARE PROVIDER COMPLETE THE REMAINDER. IT IS YOUR RESPONSIBILTY TO RETURN THE COMPLETED FORM TO THE FRIEND OF THE COURT. Name Name(s) and age(s) of child(ren) involved in this case: Are you receiving financial assistance for childcare from any federal or state agency? If yes, please state the agency and the amount you are receiving. Yes No CHILDCARE PROVIDER INFORMATION Please attach a schedule of your most recent child care rates. The Child Care Provider(s)must complete the remainder of this form for the above named child(ren) Name of provider City Address State County School year rates Name & age of child Zip Average number of hours/week Name of provider City Name & age of child Area code & Telephone no. Hourly rate Total weekly rate Address State Zip County School year rates Average number of hours/week Area code & Telephone no. Hourly rate Total weekly rate Do you require payment services even when children are absent to guarantee a position in your center? Yes No If yes, please explain: Does a Federal or State agency contribute all or a portion of these child care services? Yes No If yes, please provide agency name and amount contributed. The above information is provided to enable the Friend of the Court to accurately report childcare costs in making a child support recommendation. I certify that the above information is true, accurate and complete. Date Signature and title of provider 2001 © American LegalNet, Inc.