COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Approved, SCAO : STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY Original - Court 1st copy - Plaintiff 2nd copy - Defendant 3rd copy - Friend of the Court file Index No. Calendar No. CASE NO. : CHILD SUPPORT RECOMMENDATION JUDICIAL Plaintiff(s) WORKSHEET A -against- SUBPOENA : {print only the line items that are selected or calculated by the system} : Recommendation Number : WEEKLY INCOME $ Plaintiff Defendant WEEKLY DEDUCTIONS $ Defendant(s) : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Tax. Filing Exemption Status: .. 1. Salaries and Wages Plaintiff Defendant 22. Federal income tax (including shift premium and COLA) 2. Overtime 23. State income tax THE PEOPLE OF THE STATE OF NEW YORK 3. Second job 24. Local income tax TO 4. Commissions 25. FICA 5. All bonuses/Profit sharing 26. Alimony/Spousal support GREETINGS: 6. Interest/Dividends 27. Mandatory withholdings WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , at the 28. Mandatory retirement Court located at County of 8. Pensions/Longevity 29. Other mandatory payment in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the 7. Annuity/Trust fund payments the Honorable 9. Deferred Comp/IRA 30. Court ordered health insurance 10. Unemployment benefits 31. Court ordered life insurance Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to 32. Weekly Deductions the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to 12. Sick benefits/Disability paycomply. 11. Strike pay/Sub pay 13. Worker's compensation Witness, Honorable Court in 14. Social Security benefits County, 33. Weekly Net Income of the Justices of the , one day of 15. VA/GI benefits excluding education allotment , 20 34. Adjustments to Net Income 35. Weekly Adjusted Net Income (Attorney must sign above and type name below) 16. Armed Service/National Guard 17. Imputed Income 18. Rental allowance/income allowance if fringe from employer 19. Alimony/Spousal support 20. Adoption subsidies/other 21. Weekly Gross Income {Item 34. from Worksheet B} {on-line help for items 2, 3, 9, 30, 31, and 39} FOC 34 (12/95) 36. Combined Total of Weekly Adjusted Net Income Attorney(s) for 37. Plaintiff's Percentage of Weekly Adjusted Net Income 38. Defendant's Percentage of Weekly Adjusted Net Income Office and P.O. Address 39. Children's Social Security Benefits Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: CHILD SUPPORT RECOMMENDATION WORKSHEET A American LegalNet, Inc. www.USCourtForms.com