The Financial information Form is for the FOC use only. DO NOT FILE WITH THE COUNTY CLERK. Present this information to FOC Scheduling Office located in room 900 A of the Coleman A Young Municipal Center when filing a motion. Bring the document to the Court hearing if you are responding to a motion. FINANCIAL INFORMATION FORM FOR CHILD SUPPORT MODIFICATION I am submitting this Financial Information Form to be considered by the Court in connection with my motion to modify the child support obligation in my case. In the event the Court wishes to contact my employer, I authorize my employer to release my payroll information. I make application to the Wayne County Friend of the Court for continuing child support services under the provisions of the Child Support Enforcement Program as required under Title IV-D. I declare that the statements made in this form are true to the best of my information, knowledge and belief. DATE:_______________ SIGNATURE:__________________________________________________ CASE NUMBER: ________________________ YOUR NAME_______________________ YOUR EMAIL ADDRESS: __________________YOUR SOCIAL SECURITY NUMBER:__________________ 1. CHILDREN COVERED BY THIS SUPPORT ORDER: Name Date of Birth Address __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 2. PLEASE CHECK THE FOLLOWING SOURCES OF INCOME THAT YOU RECEIVE: a. Monthly Gross Wages (before deductions) ______________ Occupation: ______________________ American LegalNet, Inc. www.FormsWorkFlow.com ATTACH PAYSTUB Employer Name's Address Phone number __________________________________________________________________ b. Second Job Gross Wages (before deductions) ______________ Occupation: ______________________ ATTACH PAYSTUB Employer Name's Address Phone number ________________________________________________________________________ If you do not receive a paystub for your earnings, you must verify under oath that this represents your actual income. The penalties for perjury may apply if you misrepresent your income. 3. Unemployment:__________________________ (amount per week and how long you have been receiving the unemployment. 4. Other sources of income: Please state amount received and for what period (week/month/year) Sub Pay: Stock Dividends: Bonus & Profit Sharing: Rental Property Income: Social Security Benefits: Veteran Benefits: Pension: Disability Income: Spousal Support: $_____________________ $_____________________ $_____________________ $_____________________ $_____________________ $_____________________ $_____________________ $_____________________ $_____________________ American LegalNet, Inc. www.FormsWorkFlow.com Other: $_____________________ 5. PLEASE INDICATE WHETHER YOU PAY ANY INSURANCE PREMIUMS: MEDICAL PREMIUMS DENTAL PREMIUMS: OPTICAL PREMIUMS: $_____________________ $_____________________ $_____________________ Individuals Covered by policy Name Age Relationship __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ COURT ORDERED LIFE INSURANCE PREMIUMS_________________ 6. ARE YOU PRESENTLY MARRIED? _________ NAME OF SPOUSE: _______________________ DATE OF MARRIAGE: ___________________ 7. PLEASE LIST ALL OTHER CHILDREN YOU HAVE: Name Date of Birth Address Indicate: biological/adopted/step __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com 8. PLEASE LIST OTHER SUPPORT ORDERS YOU PAY ON ­ Case number County Obligation Arrearage Due Current Support ________________________________________________________________________ ________________________________________________________________________ 9. DO YOU RECEIVE STATE OR FEDERAL GOVERNMENT ASSISTANCE (i.e. FIA/TANF Assistance)? LIST CASE NUMBER ___________CASH GRANT AMOUNT ___________________ MEDICAID: YES OR NO FOOD STAMPS AMOUNT __________________ YOU MUST ATTACH VERIFICATION OF ALL SOURCES OF INCOME AND VERIFICATION OF CHILD CARE EXPENSES IF APPICABLE. FAILURE TO DO SO MAY RESULT IN DISMISSAL OF YOUR MOTION. DATE:____________________ SIGNATURE_____________________________________ American LegalNet, Inc. www.FormsWorkFlow.com