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 envelop 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 envelop 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 Employeer 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 pemium)

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 fun 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