STATE OF MICHIGAN COUNTY OF WAYNE THIRD JUDICIAL CIRCUIT COURT FAMILY DIVISION CASE NO. (MUST BE PROVIDED) CHILD CARE VERIFICATION FORM (SSN IF CASE NO. IS NOT KNOWN) 550 Penobscot Building 645 Griswold, Detroit, MI 48226 PARENT OR CUSTODIAL PERSON INFORMATION: Complete the top portion of this form and have your childcare provider complete the remainder. It is your responsibility to return the completed form to the Friend of the Court. Name of custodial parent or person: 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? YES NO If so, please state the amount you are receiving and the agency name. AMOUNT: $______ per _____ AGENCY: 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 of parent or custodial person CHILD CARE PROVIDER INFORMATION: Please attach a schedule of your most recent childcare rates. The Child Care Provider must complete the remainder of this form for the above named children. Address Name of Provider City State Zip Name and age of Child School Year Rates County Avg. No. of Hours/week Telephone No. Hourly rate Do you require payment for services even when children are absent to guarantee a position in your center? If yes, please explain: Does a Federal or State agency pay all or a portion of these childcare services? Total Weekly Rate YES YES NO NO If yes, please state the amount paid and the agency name. AMOUNT: $________ per ________ AGENCY: 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 FD/FOC4036 (03/03) Signature and title of provider CHILD CARE VERIFICATION American LegalNet, Inc. www.FormsWorkflow.com