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. Docket Number (Case Number)
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. PLEASE FILL OUT THIS SECTION IF YOU ARE UNEMPLOYED AND NOT WORKING:

114. Please provide your prior employment history
116. Employer
117. Wage
118. Dates Employed
120. Reason for Leaving
121. Hours Worked Per Week
123. Employer
124. Wage
125. Dates Employed
127. Reason for Leaving
128. Hours Worked Per Week
130. Employer
131. Wage
132. Dates Employed
134. Reason for Leaving
135. Hours Worked Per Week
137. Employer
138. Wage
139. Dates Employed
141. Reason for Leaving
142. Hours Worked Per Week
144. Employer
145. Wage
146. Dates Employed
148. Reason for Leaving
149. Hours Worked Per Week
151. Do you have any personal history that prohibits you from working (ex. criminal history; physical/mental health ailments, etc)?

     1. Yes
     2. No
153. If you selected yes above, please explain
155. Did you graduate high school?

     1. Yes
     2. No
156. Did you earn a GED?

     1. Yes
     2. No
157. Did you attend/graduate college?

     1. Yes
     2. No
159. If you attended college, please list the highest degree earned or courses taken
161. Do you have any certifications?

     1. Yes
     2. No
162. If you have certifications, please list them and if they are active or expired
164. Are you seeking employment

     1. Yes
     2. No
165. If you are seeking employment, please list the places you have applied
167. If you are seeking employment, are you looking for:

     Please check all that apply

     1. Full-time Employment
     2. Part-time Employment
168. What hours are you available to work?

     Please check all that apply

     1. Daytime Hours
     2. Evening Hours
     3. Overnight Hours
     4. Anytime
169. What days are you available during the week?

     Please check all that apply

     1. Monday-Friday
     2. Weekends only
     3. Anytime
170. If you have applied for employment, what is the potential rate of pay?
172. Do you have a driver's license?

     1. Yes
     2. No
173. Do you have a vehicle?

     1. Yes
     2. No
177. INFORMATION REGARDING THE OTHER PARENT (if known)
179. Address
181. City
182. State
183. Zip Code
185. Phone Number
186. Email Address
188. Drivers License Number
189. Last 4 numbers of Social Security Number
191. Other Parent's Employer’s Name, Phone Number and Address
193. City
194. State
195. Zip Code
199. LIST PERSONS IN HOUSEHOLD
201. Type in Full Names, Relationship, Age and Grade in School
205. INSURANCE INFORMATION
207. *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.
209. Do you or does someone in your household maintain health insurance for your minor child/ren?

     1. Yes
     2. No
211. If yes, please list the name of the policy holder
213. Is this insurance Medicaid/other State Insurance?

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

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

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

     1. Yes
     2. No
225. If yes, please provide the type of account
227. If yes, please provide your contribution amount
228. Please select frequency of Your Contribution

     1. Weekly
     2. Bi-weekly
     3. Semi-monthly
     4. Monthly
     5. Annually
230. If yes, please provide your employer's contribution amount
231. Please select frequency of Employer Contribution

     1. Weekly
     2. Bi-weekly
     3. Semi-monthly
     4. Monthly
     5. Annually
233. 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.
235. Please attach a copy of MEDICAL cards (front and back).
237. Do you need to attach an additional image?

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

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

     1. Yes
244. Please attach additional image for insurance card.
246. List the cost for you to maintain insurance per pay period.
248. List the individuals and their ages covered under the policy:
250. Please List the Names and Ages for Other Biological or Adopted Minor Children NOT ON THIS CASE
254. 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.
256. Download Childcare Expenses Form
     Childcare Expenses Form
257. Upload Childcare Expenses Form
261. Please provde the Names and Grades in School for CHILDREN OF THIS CASE ONLY (Use N/A if not in school)
265. 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.
267. Union Dues

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

     1. Yes
     2. No
273. Fixed amount per pay period
     If you contribute a fixed amount per pay period, please provide the amount per pay period.
274. Percentage per pay period
     If you contribute a percentage per pay period, please provide the percentage amount.
276. Other Mandatory Withholdings
     Please list/describe other mandatory withholding's. Please provide a cost per pay period for each additional withholding.
278. Documentation proving mandatory contributions
281. If you want Friend of the Court services, you must check the box below.

     1. I request child-support services pursuant to the child-support enforcement program of Title IV-D of the Social Security Act.

283. REMINDER LIST

     • Have you signed this questionnaire?
       
     • Have you attached your four most recent paycheck stubs, verification of other sources of income, or a statement from your employer(s) of wages, deductions, and year-to-date earnings?
     • Have you attached a copy of your last federal and state income tax returns, including all schedules, W-2's, and 1099's? If self-employed, also attach a copy of your three most recent business tax returns and/or corporation returns.
     • If unemployed, you have filled out the unemployment section of this questionnaire
     • Documentation of health insurance/medical coverage for child/ren 
     • Childcare Verification Form if utilizing childcare for child/ren of this case only

     **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 options available at the top of this form.
     

     
     

287. 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.
289. Electronic Signature*
Leave This Blank:


291. 1. Receive an email copy of this form.
292. Email address

     This field is not part of the form submission.

293. Submit

* indicates a required field