STATE OF MICHIGAN 54TH JUDICIAL CIRCUIT TUSCOLA COUNTY CASE NUMBER NOTIFICATIONS TO THE FRIEND OF THE COURT Please type or print information. Complete only those sections that apply. You can only file changes for yourself or those minor children of whom you have physical custody. You may attach additional pages if necessary. *****YOU MUST SIGN THIS FORM***** Name: Last 4 digits of Social Security Number: Signature: Date: Name of Other Party: NEW ADDRESS AND/OR TELEPHONE NUMBER Street Address: City: State: Zip: Telephone Number: ALTERNATE ADDRESS If the court has entered an order making your address confidential under Michigan Court Rule 3.203(F), the following is an alternate address for the court, the Friend of the Court, and the other party to use in serving you with notice of court papers. You are responsible for retrieving mail regarding this case from this alternate address. Street Address: City: State: Zip Code: EMPLOYMENT INFORMATION Employer: Street Address: City: State: Full or Part Time: Start Date: Zip Code: Telephone Number: Rate of Pay: (Please check all that apply) _____ I have been terminated effective _______ _____ I am laid off effective ________ _____ I am on sick leave/disability (please circle one) Hours Per Week: ______ I will receive unemployment ______ I will return on ______________ ______ I am collecting Worker’s Compensation. HEALTH INSURANCE INFORMATION Is health Insurance available to you? Yes ___ No ___ Will insurance be offered at a later date? Yes ___ No ___ Do you pay for health insurance? Yes ____ No ____ If yes, what is the cost per week $ _____________. NAME CHANGE (Please attach order changing name or certificate of marriage) New Name: (Print) *CCHG* American LegalNet, Inc. www.FormsWorkFlow.com