Approved, SCAO Original - Friend of the court Additional copies as needed STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY Friend of the court address CASE NO. CHILD-CARE VERIFICATION Telephone no. 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 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 child(ren) named above. Name of provider Address City State Zip County Area code and Telephone no. Total Weekly Rate Name and Age of Child School Year Rates Average No. of Hours/Week Hourly Rate Name and Age of Child Summer Season Rates Average No. of Hours/Week Hourly Rate Total Weekly Rate Do you require payment for services even when children are absent to guarantee a position in your center? Yes No If yes, please explain. Does a federal or state agency or a public or private entity contribute all or a portion of the cost of child-care services? If yes, please provide the agency name and amount contributed. Yes No The information above 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 information provided above is true, accurate, and complete. Date FOC 39e (3/14) Signature and title of provider CHILD-CARE VERIFICATION American LegalNet, Inc. www.FormsWorkFlow.com