JIS CODE: RFF Approved, SCAO STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION COUNTY REQUEST FOR FINANCIAL INFORMATION TO WHOM IT MAY CONCERN: CASE NO. PETITION NO. I authorize my employers, creditors, and others who may have knowledge of my financial affairs to release information to the above court. A photocopy of this authorization shall suffice as an original. Date Signature Signature Please send information on the items checked below regarding: Name DOB EMPLOYMENT INFORMATION (or subsidy) Soc. sec. no. or employee/badge no. Hire date Number of dependents claimed EARNINGS Hourly Wage ................................................................ $ DEDUCTIONS (other than taxes) Union dues ( check if required) $ per Average regular hours worked per week X Insurance $ per Weekly straight-time pay $ Credit union $ per Average overtime pay per week $ $ per $ per $ per $ per $ per $ per $ per Salary ................................................ OTHER COMPENSATION FINANCIAL INFORMATION ASSETS (checking, savings, stocks, bonds, IRAs, etc.) ( check if required) $ per OTHER (Pension, deferred compensation, stock plan, etc.) To be completed by banks, savings and loans, credit unions, loan companies, brokerage firms, etc. LOANS Balance/Value Payment Balance $ Real Estate: $ $ per $ Original loan Motor $ Vehicle: $ per $ Make and year $ per $ $ $ per $ $ Date $ $ per $ Signature Title PLEASE RETURN THE ABOVE INFORMATION BY TO THE ADDRESS AT LEFT. Date THANK YOU. JC 37 (9/07) REQUEST FOR FINANCIAL INFORMATION American LegalNet, Inc. www.FormsWorkflow.com