Approved, SCAO STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY Friend of the court address EMPLOYER'S DISCLOSURE OF HEALTH INSURANCE AND/OR INCOME INFORMATION CASE NO. Telephone no. NOTICE TO EMPLOYER Under Michigan law, you are required to provide information according to MCL 552.518. Complete both sides. Return this completed form to the friend of the court at the above address. Date Name of person preparing form (type or print) Telephone no. The information obtained from this disclosure form will be treated as confidential and will not be used or released except for purposes of administering, enforcing, and complying with state and federal laws governing child support. Name of contact (type or print) Title Telephone no. Date 1. Employee name 3. Social security number 6. Employer address 4. Employer name 2. Address 5. Employer federal identification no. 7. Hourly base pay 8. Shift premium 9. COLA 10. Avg. overtime 11. W-4 Exemp. 12. Reg. work hours 13. Pay period (weekly, etc.) $ 14. No. weeks paid this yr. 15. Date hired /week /week 18. Is this person receiving unemployment benefits? 16. Date of term. (if appl.) 17. Reason for leaving Yes No Calculate year-to-date figures as of last pay period. 19. INCOME Reg. Earnings (incl. shift prem. and COLA) Overtime Commissions Pension and and Bonuses Longevity Profit Sharing Other (explain) Gross Deferred income in addition to gross Year to Date Last Calendar Year 20. RETIREMENT CONTRIBUTIONS Mandatory Employee Voluntary Employee Employer Year to Date Last Calendar Year 21. OTHER INCOME Year to Date Last Calendar Year 22. Disability Workers Comp. Sick Pay SUB Pay Disability carrier Worker's compensation carrier WITHHOLDING Federal Income Tax F.I.C.A. State Income Tax Local Income Tax Mandatory Professional or Union Dues Alimony and Child Support Mandatory Withholding (explain) Year to Date Last Calendar Year Complete the Insurance Information on the other side. FOC 22 (3/16) American LegalNet, Inc. www.FormsWorkFlow.com EMPLOYER'S DISCLOSURE OF HEALTH INSURANCE AND/OR INCOME INFORMATION MCL 552.518 23. Check all that apply Employer offers a medical flexible spending account. Dependent insurance not offered to employees. Dependent insurance medical dental optical is offered to the employee but the employee has not enrolled. (Attach information regarding dependent coverages and cost.) Employee will be eligible for dependent insurance. Date available: (Attach information regarding dependent coverages and cost.) Employee has enrolled for dependent insurance. (Complete items 24 through 29. If you need additional space, use the space below.) 24. Medical insurance company name, address, telephone no. Policy no. and Group no. 26. Optical insurance company name, address, telephone no. Policy no. and Group no. 28. What dependent coverage is offered? Specify cost to employee employee only individual plus one per family 25. Dental insurance company name, address, telephone no. Policy no. and Group no. 27. Other insurance (i.e. prescription, mental health) Medical $ Name per DOB Dental $ Relationship per Medical Optical $ Dental per Optical 29. What dependents of employee are covered? Effective Date of Coverage Use this space for any necessary explanations. American LegalNet, Inc. www.FormsWorkFlow.com