Approved, SCAO Original - Friend of the court 1st copy - Plaintiff/Attorney 2nd copy - Defendant/Attorney STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY 1. Parent's last name 3. Date of birth First name CASE NO. VERIFIED STATEMENT Middle name 4. Social security number 2. Any other names by which parent is or has been known 5. Driver's license number and state 6. Mailing address and residence address (if different) 7. E-mail address 8. Eye color 9. Hair color 10. Height 11. Weight 12. Race 13. Gender 14. Scars, tattoos, etc. 15. Home telephone no. 16. Work telephone no. 17. Occupation 19. Gross weekly income 18. Business/Employer's name and address 20. Did this parent apply for or receive public assistance? If yes, please specify kind and case number. Yes No First name Middle name 24. Social security number 22. Any other names by which parent is or has been known 25. Driver's license number and state 21. Other parent's last name 23. Date of birth 26. Mailing address and residence address (if different) 27. E-mail address 28. Eye color 29. Hair color 30. Height 31. Weight 32. Race 33. Gender 34. Scars, tattoos, etc. 35. Home telephone no. 36. Work telephone no. 37. Occupation 39. Gross weekly income 38. Business/Employer's name and address 40. Did this parent apply for or receive public assistance? If yes, please specify kind and case number. Yes No M / F b. Birth date c. Age d. Soc. sec. no. e. Residential address 41. a. Name and sex of minor child in case 42. a. Name and sex of other minor child of either party M / F b. Birth date c. Age d. Residential address 43. Health care coverage available for each minor child a. Name of minor child b. Name of policy holder c. Name of insurance co./HMO d. Policy/Certificate/Contract/Group no. 44. Name(s) and address(es) of person(s) other than parties, if any, who may have custody of child(ren) during pendency of this case. I declare that the statements above are true to the best of my information, knowledge, and belief. Date Signature If any of the public assistance information above changes before your judgment is entered, you are required to give the friend of the court written notice of the change. If you want child support services, complete form DHS 1201-D, available at your local friend of the court office or courts.mi.gov/Administration/ SCAO/Forms/courtforms/domesticrelations/generalfoc/dhs1201d.pdf FOC 23 (3/16) VERIFIED STATEMENT American LegalNet, Inc. www.FormsWorkFlow.com MCR 3.206(B)