Approved, SCAO STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY CASE NO. EMPLOYER'S DISCLOSURE OF INCOME AND HEALTH INSURANCE INFORMATION Friend of the court address Telephone no. The information obtained will be treated as confidential and shall not be used or released except for the purposes of administering, enforcing, and complying with state and federal laws governing child support. Title Name of contact (type or print) Telephone no. 1. Employee name Date 2. Address 3. Social security number 5. Employer federal identification no. 4. Employer name 6. Employer address Complete items 7, 8, and 9 if insurance is available to employee. 7. Medical insurance company name, address, telephone no. Policy number 8. Dental insurance company name, address, telephone no. Policy number 9. Optical insurance company name, address, telephone no. Policy number 10. What dependent coverage is automatically available? Medical Dental 11. What dependent coverage is available by payment of an additional premium? Specify cost to employee Medical per Dental per 15. COLA Relationship 16. Avg. overtime $ 20. No. weeks paid this yr. 21. Date hired per Effective Date of Coverage DOB 13. Hourly base pay 14. Shift premium per family Optical 12. What dependents of employee are covered? Name Optical per individual Medical Dental Optical 17. W-4 Exemp. 18. Reg. work hours 19. Pay period (weekly, etc.) /week /week 22. Date of term. (if appl.) 23. Reason for leaving 24. Is this person receiving unemployment benefits? Yes No Calculate year to date figures as of last pay period. 25. Reg. Earnings (incl. shift prem. and COLA) Overtime Commissions and Bonuses Pension and Longevity Disability INCOME Workers Comp. Sick Pay SUB Pay Profit Sharing Other (explain) Gross Deferred income in addition to gross Year to Date Last Calendar Year 26. OTHER INCOME Disability carrier Year to Date Last Calendar Year 27. WITHHOLDING Worker's compensation carrier 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 Sign and return to the friend of the court address listed above. Use other side if necessary. See the notice on the other side. Date FOC 22 (3/08) Name and signature of person preparing form Telephone no. EMPLOYER'S DISCLOSURE OF INCOME AND HEALTH INSURANCE INFORMATION American LegalNet, Inc. www.FormsWorkflow.com NOTICE TO EMPLOYER Pursuant to Michigan law, you are required to provide information relative to the custodial or absent parent as follows: Sec. 18.(1) Subject to subsection (3) and (4), upon the request of the office of the friend of the court, any employer or former employer of a parent as defined in section 1 of the office of child support act, 1971 PA 174, MCL 400.231, who is or was employed as an employee or independent contractor, shall provide the following information relative to the custodial parent or absent parent: (a) Full name and address. (b) Social security number (unless the parent is exempt under state or federal law). (c) Date of birth. (d) Amount of wages earned by or other income due the custodial parent or absent parent. Both net and gross income shall be reported, regardless of the method of payment. (e) The following information concerning the person's current and former employment status: whether or not the custodial parent or absent parent is currently employed, laid off, or on sick, disability, or other leave of absence, or retired and the amount of income due from an employment-related benefit plan, if any. (f) Dependent health-care coverage available to the custodial parent or absent parent as a benefit of employment. Use this space for any necesesary explanations from the other side. American LegalNet, Inc. www.FormsWorkflow.com