weeklybiweeklybimonthlymonthlymarriedsinglehead of householdweeklybiweeklybimonthlymonthly1.Your full name2.Date of birth3.Place of birth: city and state4. AddressCityStateZip5. Home telephone 6. Work telephone7.Social security number 8. Driver's license no. 9. Professional license, type, and no. 10. Cell phone 11. E-mail address12.Sex13.Eye color14.Hair color15.Height16.Weight17.Race18.Scars, tattoos, etc.19.Your father's full name20.Your mother's full maiden name21.Names of children in common with other parent in this case Birthdate Gender Soc. sec. no. Address No. of overnights you have w/ child annually22. Names of all additional minor children you support Birthdate Address23. 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?25.Your occupation26. Your employer (if unemployed, name of last employer)27. Employer's addressCityStateZip 28. Date hired29. Gross earnings per pay period (earnings before taxes)30.Filing status dependents claimed$31.Hourly pay rate (including shift premium32.Total regular hours worked per pay period33. Average overtime hours for past 12and COLA)months34.Second job35. Employer36.Employer's addressCityStateZip37. Date hired38. Gross earnings per pay period (earnings before taxes)39.Hourly pay rate40.Average hours worked per$ pay period since hire date41.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 employerAddress of last full-time employerPosition held at last place of full-time employmentLast day employed full-timeLength of time employed in last full-time positionReason for leaving last full-time employmentGross earnings per pay period (earnings before taxes)$FOC 39 (3/14) FRIEND OF THE COURT - CASE QUESTIONNAIRE (Page 1) FRIEND OF THE COURTCASE QUESTIONNAIRE(Page 1) Friend of the court address Telephone no. Plaintiff DefendantvJUDICIAL CIRCUITCOUNTYSTATE OF MICHIGAN CASE NO.Approved, SCAO YOUR GENERAL INFORMATION M F YesNo YesNo YOUR INCOME, MEDICAL, EDUCATIONAL, AND HEALTH INSURANCE INFORMATION weeklybiweeklybimonthlymonthly Complete this form and sign on page 4. YesNo American LegalNet, Inc. www.FormsWorkFlow.com 42.List MONTHLY income from all other sources, such as:CommissionsUnemp. BenefitsNat'l. Guard & Res. Drill PayBonusesStrike PayArmed ServicesProfit SharingSUB PayAllowance for RentInterestSick BenefitsRental IncomeDividendsWorker's Comp.Spousal Support/AlimonyAnnuitiesSoc. Sec. BenefitsState Disability AssistancePensions/LongevityVA BenefitsF I PDeferred Comp./IRADisability InsuranceSupp. Security Income SSITrust FundsGI BenefitsOther43.Do you have any spousal support/alimony orders involving another person not a parent in this case?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 state44.Do any of the children listed on item 21 and 22 receive payments from the Social Security Administration?Child'sAmountType of benefit (check one)Source of dependent benefitName(monthly)SSIDependent 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 copyof your last federal and state income tax returns, including all schedules. If self-employed, also attach a copy of your three most recent businesstax 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:47.What is your educational background? (Check one)Less than high schoolHigh school graduateTrade school graduateAssociate's degreeBachelor's degreeGraduate degree48. Medical insurance company name, address, telephone no.Policy/Group numberBeginning date, if known49. Dental insurance company name, address, telephone no.Policy/Group numberBeginning date, if known50. Optical insurance company name, address, telephone no.Policy/Group numberBeginning date, if known51. What dependent coverage is available to you without cost?52. What dependent coverage is available by payment of an additional premium? (Specify cost per pay period.)53. Individuals currently covered by your insuranceNoYes, as payerYes, as recipientFOC 39 (3/14) FRIEND OF THE COURT - CASE QUESTIONNAIRE (Page 2) JUDICIAL CIRCUITCOUNTYFRIEND OF THE COURTCASE QUESTIONNAIRE(Page 2)STATE OF MICHIGAN CASE NO.Approved, SCAO YesNo YOUR INCOME, MEDICAL, EDUCATIONAL, AND HEALTH INSURANCE INFORMATION (continued)YesNo NameBirthdateRelationshipMedical ()Dental ()Optical () MedicalperDentalperOpticalperMedicalDentalOptical American LegalNet, Inc. www.FormsWorkFlow.com YesNo54.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 providerNames of children receiving child careNumber of weeks provided during last calendar yearEstimated number of weeks of child care provided in this calendar yearCurrent weekly child-care costAmount of child-care credit received on last year's federal I.R.S. tax returnDoes 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.Work relatedLooking for employmentEnrolled in educational program toimprove employment opportunities56.If your reason for child care is education related, provide the following information.Name of educational institutionTotal classroom hours per weekEducational goalProjected graduation date57.List any additional information that would be useful to the court in making a support recommendation.58.Full name59.Date of birth60.Place of birth: city and state61. AddressCityStateZip 62.Home telephone 63. Work telephone64.Social security number 65. Driver's license number 66. Professional license, type, and no. 67. Cell phone 68. E-mail address69.Sex70.Eye color71.Hair color72.Height73.Weight74.Race75.Scars, tattoos, etc.76.Father's full name77.Mother's full maiden name78.Names of all additional minor children he/she supports Birthdate Address79.Is this party pregnant?a. When is the child due? b. Is the party in this case the biological parent of the expected child? 80. Is this parent married?81.Occupation 82. Employer (if unemployed, name of last employer)83. Employer's addressCityStateZip 84. Date hired85. Gross earnings per pay period (earnings before taxes)86.Average overtime hours for past 12 monthsFOC 39 (3/14) FRIEND OF THE COURT - CASE QUESTIONNAIRE (Page 3) Reason Estimated number of hours per week JUDICIAL CIRCUITCOUNTYFRIEND OF THE COURTCASE QUESTIONNAIRE(Page 3)STATE OF MICHIGAN CASE NO.Approved, SCAO YOUR CHILD-CARE INFORMATION YOUR ADDITIONAL INFORMATION INFORMATION REGARDING THE OTHER PARENT IN THIS CASE (if known) M F YesNo YesNo YesNo American LegalNet, Inc. www.FormsWorkFlow.com 87. Medical insurance company name, address, telephone no.Policy/Group numberBeginning date, if known88. Dental insurance company name, address, telephone no.Policy/Group numberBeginning date, if known89. Optical insurance company name, address, telephone no.Policy/Group numberBeginning date, if known90. What dependent coverage is available to the other parent without cost?91. What dependent coverage is available by payment of an additional premium? (Specify cost per pay period.)92. Individuals currently covered by other parent's insuranceIf you want friend of the court services, you must check the box below.I request child-support services pursuant to the child-support enforcement program of Title IV-D of the SocialSecurity Act.I declare that the information in this questionnaire is true to the best of my information, knowledge, and belief.Reminder List225Have you signed this questionnaire?225Have you completed item 21 regarding the number of overnights you have with the child annually? Failure to specifywill result in the frie