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Employers Disclosure Of Income And Health Insurance Information Form. This is a Michigan form and can be use in Domestic Relations Statewide.
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Tags: Employers Disclosure Of Income And Health Insurance Information, FOC 22, Michigan Statewide, Domestic Relations
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
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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.
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