Approved, SCAO Original - Friend of the court Copies - All parties STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY DOMESTIC RELATIONS JUDGMENT INFORMATION, PAGE 1 TEMPORARY FINAL CASE NO. USE NOTE: Complete this form and file it with the friend of the court (do not file this form with the office of the clerk of the court) when the first temporary custody, parenting-time, or support order is entered and when submitting any final proposed judgment awarding custody, parenting time, or support. Mail a copy to each party and file proof of mailing with the court (may use form MC 302, Proof of Mailing). The information previously provided Date is changed is unchanged. Signature (Complete only the fields that have changed.) Plaintiff Information Name Address Defendant Information Name Address Social security number E-mail address Telephone number Social security number E-mail address Telephone number Employer name, address, telephone number, and FEIN (if known) Employer name, address, telephone number, and FEIN (if known) Driver's license number and state Occupational license number(s), type(s), issuing state(s), and date(s) Driver's license number and state Occupational license number(s), type(s), issuing state(s), and date(s) CUSTODY PROVISIONS Child's name sole, plaintiff = P sole, defendant = D joint = J other = O (must identify) Social security Date of birth number Physical custody P, D, J, O Child's primary residence address Legal custody P, D, J, O SUPPORT PROVISIONS Support provisions are stated in the Uniform Support Order. Medical Support provisions are stated on page 2 of this form. FOC 100 (3/14) DOMESTIC RELATIONS JUDGMENT INFORMATION, PAGE 1 American LegalNet, Inc. www.FormsWorkFlow.com MCR 3.211(F) Approved, SCAO Original - Friend of the court Copies - All parties STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY DOMESTIC RELATIONS JUDGMENT INFORMATION, PAGE 2 TEMPORARY FINAL CASE NO. MEDICAL SUPPORT PROVISIONS: List the name of each insurance provider for the plaintiff and the defendant. Then enter the name of each child in this case who is covered by that provider and the type of coverage provided. Plaintiff's Insurance Coverage Provider name and address Policy/Group no. Cert. no. Child(ren)'s name(s) Medical Dental Optical Other Defendant's Insurance Coverage Provider name and address Policy/Group no. Cert. no. Child(ren)'s name(s) Medical Dental Optical Other FOC 100 (3/14) DOMESTIC RELATIONS JUDGMENT INFORMATION, PAGE 2 American LegalNet, Inc. www.FormsWorkFlow.com MCR 3.211(F)