____________________________________________________________________________ STATE OF MICHIGAN CASE NUMBER 54TH JUDICIAL CIRCUIT CHILD CARE VERIFICATION TUSCOLA COUNTY FAMILY DIVISION ____________________________________________________________________________ FRIEND OF THE COURT 449 GREEN STREET, CARO, MICHIGAN 48723 Phone: (989) 673-4848 Email: foc@tuscolacounty.org Website: www.tuscolacounty.or g Fax: (989) 673-4898 PARENT INFORMATION Complete the top portion of this form and have your child care provider complete the remainder. It is your responsibility 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 child care from any Federal or State agency? ____ Yes ____ No If yes, please state the agency and the amount you are receiving. CHILD CARE PROVIDER INFORMATION Please attach a schedule of your most recent child care rates. The Child Care Provider must complete the remainder of this form for the above named child(ren). Name of Provider Address City State Zip County Area Code & Telephone No Name & Age of Child School Year Rates Ave No. of Hours/Week Hourly Rate Weekly Rate Name & Age of Child Summer Season Rates Ave No. of Hours/Week Hourly Rate Weekly Rate Do you require payment for services even when children are absent to guarantee a position in your center? ___yes ___ no If yes, 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 child care costs in making a child support recommendation. I certify that the above information is true, accurate, and complete. _________________________________ ____________________________________ Date Signature and title of provider