Friend of The Court Case Questionnaire

2. FRIEND OF THE COURT CASE QUESTIONNAIRE
4. Court Contact Information
   Telephone (989) 224-5136 Fax (989) 224-5113 100 East State Street Suite 4100 St. Johns, MI 48879
6. **Disclaimer**: As this website is a third-party entity, the Friend of the Court is unable to ensure that ANY documents uploaded to this website will be secure. If you do not wish to upload any or all of the requested documentation through this website, then you may provide the Friend of the Court with the requested documentation through one of the following means:

8. Mail to: Friend of the Court 100 E State St. Suite 4100, St Johns MI 48879

9. Fax to: 989-224-5113

10. MiChildSupport
    MiChildSupport

    If you have an established case with the Friend of the Court you may use this link.

12. You may also call the Friend of the Court office at 989-224-5136 if you have any questions about returning your documents.
16. PLEASE FILL OUT THIS FORM COMPLETELY, IF REQUIRED INFORMATION IS NOT GIVEN IT WILL NOT BE TAKEN INTO CONSIDERATION AS A POSSIBLE DEDUCTION OR ADDITIONAL EXPENSE. THIS FORM CANNOT BE SAVED. YOU CANNOT LEAVE THIS FORM AND RETURN TO IT AT A LATER TIME. PLEASE REVEIW THIS FORM TO MAKE SURE YOU HAVE EVERYTHING NEEDED TO COMPLETE IT ONCE YOU BEGIN.
20. Case Number if Known
21. Plaintiff Name
22. Defendant Name
24. Your Full Name*
25. Place of Birth: City and State*
27. Is Address New?*

    1. Yes
    2. No
29. Address*
31. City*
32. State*
33. Zip Code*
35. Home Phone Number
36. Cell Phone Number
38. Driver's License Number
39. Attach image of Drivers License
41. Email Address
43. Last 4 digits of Social Security Number
47. INCOME INFORMATION
49. Your Occupation or Job Title
50. Hiring Date
52. Employer Name
53. I am self employed

    1. Yes
    2. No

    If you are self employed, you MUST provide complete tax returns for the past three years. You may mail them to the Friend of the Court at 100 E State St., St Johns MI 48879; Fax them to 989-224-5113; use MiCASE at https://micase.state.mi.us/portalapp/public/login.html; or use the Friend of the Court drop box located on the 2nd floor of the Courthouse near security (please place in a sealed envelope). You may also call 989-224-5136 if you have any questions.
55. Employer Address
57. City
58. State
59. Zip Code
61. Employer Phone Number
62. Additional Employer Phone Number
64. Attach 1 Month of Pay Stubs
    If possible, upload this as one file. If not, you can provide additional pay stubs below.
66. Additional Pay Stubs
68. Additional Pay Stubs
70. Additional Pay Stub
72. Gross Earnings per pay period
74. Hourly pay rate (including shift premium)
75. Pay frequency

    1. weekly
    2. bi-weekly
    3. semi-monthly
    4. monthly
77. Total hours worked per pay period
78. Average overtime hours per pay period along with overtime rate
80. Second employeer (if applicable)
81. Hiring date of second employer
83. Hourly pay rate of second employer
84. Hours worked per pay period of second employeer
86. List any additional income (Retirement, Pension)
87. Additional income frequency

    1. weekly
    2. bi-weekly
    3. semi-monthly
    4. monthly
89. List any degrees/certificates/occupational licenses with year obtained
91. Do you receive Social Security Supplemental Income (SSI)

    1. Yes
93. Amount
94. SSI income frequency

    1. weekly
    2. bi-weekly
    3. semi-monthly
    4. monthly
96. Do you receive Social Security Disability (SSD, VA or Railroad Retirement)

    1. Yes
98. Describe
100. Amount
101. Frequency

     1. weekly
     2. bi-weekly
     3. semi-monthly
     4. monthly
103. List any children who receive Social Security Disability
105. Monthly Benefit Amount for the minor child(ren)
106. In whose name is the benefit received?
108. Please Attach: Any additional information that would assist in reviewing your financial situation.
112. INFORMATION REGARDING THE OTHER PARENT (if known)
114. Address
116. City
117. State
118. Zip Code
120. Phone Number
121. Email Address
123. Drivers License Number
124. Last 4 numbers of Social Security Number
126. Other Parent's Employer’s Name, Phone Number and Address
128. City
129. State
130. Zip Code
134. LIST PERSONS IN HOUSEHOLD
136. Type in Full Names, Relationship, Age and Grade in School
140. INSURANCE INFORMATION
142. *To qualify for the premium deduction for carrying health insurance on the minor children you must submit proof from the carrier’s human resource department or a paystub with proof of the health insurance deduction.
144. Do you maintain health insurance for your minor children?

     1. Yes
     2. No
146. Does anyone in your household carry health insurance for the minor children?

     1. Yes
     2. No
148. Do you maintain mandatory health insurance for yourself?

     1. Yes
     2. No
150. Do both parties take the child to the doctor?

     1. Yes
151. If one list which parent
153. Name of insurance company
154. Policy Number:
156. Does your employer fund an account that pays your uninsured medical expenses? (examples HSA/HRA)

     1. Yes
     2. No
158. If yes, please provide the type of account
160. Please attach a copy of your current insurance card FOR THE CHILDREN, front and back.
     For your medical cards to be placed on file, we need both the front and back. If possible upload this in one file. If not you can create a single image, please use the check box below.
162. Please attach a copy of MEDICAL cards (front and back).
164. Do you need to attach an additional image?

     1. Yes
165. Please attach additional image for insurance card.
167. Do you need to attach an additonal image?

     1. Yes
168. Please attach additional image for insurance card.
170. Do you need to attach an additional image?

     1. Yes
171. Please attach additional image for insurance card.
173. List the cost for you to maintain insurance per pay period.
175. List the individuals and their ages covered under the policy:
177. Please List the Names and Ages for Other Biological or Adopted Minor Children NOT ON THIS CASE
181. EMPLOYMENT HISTORY
183. Please list the previous employers held within the last two years
185. Employer
186. Wage
187. Hours Worked Per Week
189. Dates Employed
191. Reason For Leaving
193. Emoloyer
194. Wage
195. Hours Worked Per Week
197. Dates Employed
199. Reason For Leaving
201. Employer
202. Wage
203. Hours Worked Per Week
205. Dates Employed
207. Reason For Leaving
209. Do you have any personal history that prohibits you from working?
211. Are you currently seeking employment? If yes, please indicate places you have applied
213. Type of Employment Sought

     1. Full-Time
     2. Part-Time
214. Potential Rate of Pay
218. CHILDCARE EXPENSES
     Your childcare provider will need to complete the form below and sign it to verify the information is accurate. Forms returned without the signature of the provider will NOT be included when calculating support. Child Care for a child continues through August 31 following that child’s 12th birthday.
220. Download Childcare Expenses Form
     Childcare Expenses Form
221. Upload Childcare Expenses Form
225. Please provde the Names and Grades in School for CHILDREN OF THIS CASE ONLY (Use N/A if not in school)
229. Mandatory Contributions
     Does your employer MANDATORILY require you to pay any of the following?
     *to count as a deduction you must supply documentation proving the mandatory contribution.
231. Union Dues

     1. Yes
     2. No
233. If you selected Yes above, please provide the amount per pay period
235. Retirement Plan

     1. Yes
     2. No
237. Fixed amount per pay period
     If you contribute a fixed amount per pay period, please provide the amount per pay period.
238. Percentage per pay period
     If you contribute a percentage per pay period, please provide the percentage amount.
240. Other Mandatory Withholdings
     Please list/describe other mandatory withholding's. Please provide a cost per pay period for each additional withholding.
242. Documentation proving mandatory contributions
247. Electronic Signature Agreement*

     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

     1. I agree.
249. Electronic Signature*
Leave This Blank:


251. 1. Receive an email copy of this form.
252. Email address

     This field is not part of the form submission.

253. Submit

* indicates a required field