Approved, SCAO STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY CASE NO. EMPLOYMENT STATUS DISCLOSURE Telephone no. Fax number Friend of the court address 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. Contact person Title Date Telephone no. Employer name and address Name of individual ATTENTION: Social security number Our records indicate that you are the last-known employer for the individual stated above. This information may no longer be accurate. Our office may have previously issued an income withholding notice for this individual to your company. If you received a notice, please note that MCL 552.611 through MCL 552.614 require you to honor the notice. Please contact the friend of the court by completing, signing, and returning this form within 7 days of receipt by mail or facsimile at the above address or Fax number. Thank you for your cooperation; your assistance is appreciated. The individual is currently employed here and has been since . Date If the individual is not employed with you, please check the items below that apply. The individual was never employed here. The individual quit was fired was terminated was laid off on . Date The individual is receiving unemployment from: Name Address ( ) City, state, zip Telephone no. The individual is receiving benefits from: Name Workers' compensation Disability Address ( ) City, state, zip Telephone no. The individual may now be working at: Name Address ( ) City, state, zip Telephone no. The last-known address of the individual is: Address ( City, state, zip Date Name of person preparing form (type or print) Telephone no. Signature of person preparing form ( FOC 22b (3/08) EMPLOYMENT STATUS DISCLOSURE ) ) Telephone no. American LegalNet, Inc. www.FormsWorkFlow.com