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

   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

   Mail to: Friend of the Court 100 E State St. Suite 4100, St Johns MI 48879
9. Fax to: 989-224-5113

   Fax to: 989-224-5113
10. Return to the Friend of the Court drop box located on the 2nd Floor of the Courthouse. Please put any documents in an envelope if using the drop box.

    Return to the Friend of the Court drop box located on the 2nd Floor of the Courthouse. Please put any documents in an envelope if using the drop box.
11. MiCASE
    MiCASE

    If you have an established case with the Friend of the Court you may use this link.
13. You may also call the Friend of the Court office at 989-224-5136 if you have any questions about returning your documents.

    You may also call the Friend of the Court office at 989-224-5136 if you have any questions about returning your documents.
17. 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.
21. Case Number if Known
22. Plaintiff Name
23. Defendant Name
25. Your Full Name*
26. Date of Birth*
    Date of Birth
27. Place of Birth: City and State*
29. Is Address New?*

    1. Yes
    2. No
31. Address*
33. City*
34. State*
35. Zip Code*
37. Home Phone Number
38. Cell Phone Number
40. Driver's License Number
41. Attach image of Drivers License
43. Email Address
45. Last 4 digits of Social Security Number
49. INCOME INFORMATION
51. Your Occupation or Job Title
52. Hiring Date
54. Employer Name
55. 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.
57. Employer Address
59. City
60. State
61. Zip Code
63. Employer Phone Number
64. Additional Employer Phone Number
66. Attach 1 Month of Pay Stubs
    If possible, upload this as one file. If not, you can provide additional pay stubs below.
68. Additional Pay Stubs
70. Additional Pay Stubs
72. Additional Pay Stub
74. Gross Earnings per pay period
76. Hourly pay rate (including shift premium)
77. Pay frequency

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

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

    1. Yes
95. Amount
96. SSI income frequency

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

    1. Yes
100. Describe
102. Amount
103. Frequency

     1. weekly
     2. bi-weekly
     3. semi-monthly
     4. monthly
105. List any children who receive Social Security Disability
107. Monthly Benefit Amount for the minor child(ren)
108. In whose name is the benefit received?
110. Please Attach: Any additional information that would assist in reviewing your financial situation.
114. INFORMATION REGARDING THE OTHER PARENT (if known)
116. Address
118. City
119. State
120. Zip Code
122. Phone Number
123. Email Address
125. Drivers License Number
126. Last 4 numbers of Social Security Number
128. Other Parent's Employer’s Name, Phone Number and Address
130. City
131. State
132. Zip Code
136. LIST PERSONS IN HOUSEHOLD
138. Type in Full Names, Relationships and Birth Dates
142. INSURANCE INFORMATION
144. *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.
146. Do you maintain health insurance for your minor children?

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

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

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

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

     1. Yes
     2. No
160. If yes, please provide the type of account
162. 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.

     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.
164. Please attach a copy of MEDICAL cards (front and back).
166. Do you need to attach an additional image?

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

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

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

     1. Full-Time
     2. Part-Time
216. Potential Rate of Pay
220. 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.

     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.
222. Download Childcare Expenses Form
     Childcare Expenses Form
223. Upload Childcare Expenses Form
227. Mandatory Contributions
     Does your employer MANDATORILY require you to pay any of the following? <br> *to count as a deduction you must supply documentation proving the mandatory contribution.

     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.
229. Union Dues

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

     1. Yes
     2. No
235. Fixed amount per pay period
     If you contribute a fixed amount per pay period, please provide the amount per pay period.
236. Percentage per pay period
     If you contribute a percentage per pay period, please provide the percentage amount.
238. Other Mandatory Withholdings
     Please list/describe other mandatory withholding's. Please provide a cost per pay period for each additional withholding.
240. Documentation proving mandatory contributions
245. 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.
247. Electronic Signature*
Leave This Blank:


249. 1. Receive an email copy of this form.
250. Email address

     This field is not part of the form submission.

251. Submit

* indicates a required field