VERIFIED STATEMENT You must/should file this at the time the complaint is filed at with the Clerk’s Office. If you have not already done so, print this form and have your client complete it as soon as possible. 2001 © American LegalNet, Inc. CASE NO. STATE OF MICHIGAN SIXTH JUDICIAL CIRCUIT OAKLAND COUNTY 1. Mother’s last name 3. Date of birth VERIFIED STATEMENT First name Middle name 2. Any other names by which mother is or has been known 4. Social Security Number 5. Drivers license number & state 6. Mailing address and residence address (if different) 7. Eye color 8.Hair color 13. Home telephone number 9. Height 10. Weight 14. Work telephone number 11. Race 12. Scars, tattoos, etc. 15. Maiden name 16. Occupation 17. Business/Employer’s name and address 18. Gross weekly income 19. Has wife applied for or does she receive public assistance? If yes, please specify kind. 20. AFDC and recipient identification numbers Yes No 21. Father’s last name 23. Date of birth First name Middle name 22. Any other names by which father is or has been known 24. Social Security Number 25. Drivers license number 26. Mailing address and residence address (if different) 27. Eye color 28.Hair color 33. Home telephone number 29. Height 30. Weight 31. Race 34. Work telephone number 32. Scars, tattoos, etc. 35. Occupation 36. Business/Employer’s name and address 37. Gross weekly income 38. Has husband applied for or does he receive public assistance? If yes, please specify kind. 39. AFDC and recipient identification numbers Yes No 40. a. Name of minor child in case b. Birth date c. Age d. S.S. Number e. Residential address 41. a. Other minor child of either party b. Birthdate c. Age d. S.S. Number e. Residential address 42. Health care coverage available for each minor child: a. Name of minor child b. Name of policy holder c. Name of insurance company/HMO d. Policy/certificate/contract number 43. Names and addresses of person(s) other than parties, if any, who may have custody of child(ren) during pendency of this case. I request child support services available under title IV-D of the Social Security Act Yes (enforcement, locator, future modification). Answering “YES” allows Oakland County to qualify for federal funding. FOC (5/97) Applicant’s Signature (required): I declare that the statements The Friend of the Court will not discriminate against any individual or group above are true to the best of because of race, sex, religiion, age, national origin, color, marital status, my information and belief. political beliefs, or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known at the Friend of the Court office. Date: 2001 © American LegalNet, Inc.