Approved, SCAO Original - Friend of the court 1st copy - Requesting party as needed 2nd copy - Other party as needed 3rd copy - Court as needed STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY Friend of the court address CASE NO. STATEMENT OF ACCOUNT Telephone no. Plaintiff's name and address v Defendant's name and address 1. Name of payer: 2. Date of support order: 3. I certify that as of Date the overdue support and other obligations on the records of the Michigan Child Support Enforcement System were: Frequency of payment Type of payment a. Child support b. Spousal support c. Fixed obligation d. Confinement/ Medical expenses e. Service fees f. Other Charge amount Overdue amount Total 4. Last payment date: Last payment amount: Date Signature Name (type or print) Title American LegalNet, Inc. www.FormsWorkFlow.com FOC 55 (3/16) STATEMENT OF ACCOUNT MCL 552.2602(1)(c)