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2. If you think you have good reasons for the Friend of the Court (FOC) to discharge or waive your state-owed debt, please complete all information on this form. You may include more pages if you need more space. You may be asked to fill out more paperwork or provide proof of any of this information. FOC staff may schedule a follow-up meeting with you in person or by phone. Please note that submission of this form is for Clinton County Friend of the Court. If you have a court order in more than one county, please contact the other FOC county office where your additional case(s) are located in regards to seeking discharge of state-owed debt.
4. **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:

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

7. Fax to: 989-224-5113

8. MiChildSupport
   MiChildSupport

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

10. You may also contact the Friend of the Court at 989-224-5136 if you have any questions about this form
14. 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.
16. PERSONAL INFORMATION
18. First Name*
19. Last Name*
21. Address*
23. City*
24. State*
25. Zip Code*
27. Phone Number
28. Fax Number
30. Email Address
32. Driver's license or state ID number
33. Last 4 of your Social Security Number
35. Custodial party name*

    Please include current last name and any previously used last names if applicable/known

37. Docket Number (Case Number)
41. YOUR SITUATION
43. Persons in your household
    Above, please list who lives in your household (including any children). Please provide the age and how each person is related to you. Ex. Name-Age-Relation
45. Does anyone have income/help pay household expenses

    1. Yes
    2. No
47. If you selected yes above, please list which person(s) in your home have income or help pay household expenses
49. In your living situation, do you

    1. Rent
    2. Own
    3. Other
51. If other, please explain:
53. If you have other child support cases in other states, please provide which state and a case number(s) if known.
55. How much can you pay in current child support per month?
56. How much can you pay toward past-due support per month?
58. Would you be able to pay at least $1,000 at one time if the FOC "matched" the payment amount by discharging an equal amount of your state-owed debt?

    1. Yes
    2. No
60. If no, what amount could you pay all at one time to qualify for a matching discharge?
62. Select your highest level of education:

    1. Some high school
    2. High school diploma
    3. Some college

    1. Two-year college degree (associate's)
    2. Four-year college degree (bachelor's)
    3. Graduate degree (master's, J.D., etc)
64. Do you have any specialized job training or licenses (examples: apprenticeship, certification, etc)? If yes, please describe:
66. Are you employed:

    1. Full-Time
    2. Part-Time
    3. Unemployed
67. If unemployed, are you eligible for unemployment benefits?

    1. Yes
    2. No
69. If no, why not?
71. If unemployed at any time in the past three years, please identify which months you were unemployed and not receiving unemployment benefits. (You weren't eligible for benefits, or they had run out) (Examples: 1/2011, 4/2012, etc)
73. Current Employer Name (if you have one)
75. Address
77. City
78. State
79. Zip Code
81. Phone Number
83. Are you currently incarcerated (in jail or prison)?

    1. Yes
    2. No
85. If yes, please complete the following:
87. Prisoner ID:
89. Date you expect to be released:
91. Prison/Jail Location:
93. Have you been incarcerated in the past?

    1. Yes
    2. No
95. If yes, please list approximate start and end dates:
97. Start
98. End
100. Start
101. End
103. Start
104. End
106. If you have been incarcerated previously, is it hard for you to find employment because of your previous jail, prison, or probation sentences?

     1. Yes
     2. No
108. If yes, please explain:
110. Are you receiving Social Security payments?

     1. Yes
     2. No
111. Date you began receiving payments?
113. Type of payments:

     1. SSI
     2. Disability
     3. Retirement
114. Are you permanently disabled according to the Social Security Administration (SSA)?

     1. Yes
     2. No
116. If you are receiving social security payments, please upload a copy of your award letter or other proof for the Friend of the Court
117. If you are permanently disabled according to the SSA, please upload your proof for the Friend of the Court
119. Do you have a disability or orther health issue(s) that may prevent you from working full-time, or from working at all?

     1. Yes
     2. No
121. If yes, please upload your proof for the Friend of the Court
123. Do you currently receive public assistance (FIP, Medicaid, Food Stamps, etc)?

     1. Yes
     2. No
125. If yes, what kind of assistance
127. Are you currently under a bankruptcy plan, or are you in the process of filing bankruptcy?

     1. Yes
     2. No
128. Do you expect to receive money from a will, estate, or trust?

     1. Yes
     2. No
130. Are you currently living in a homeless shelter or taking part in a homlessness program?

     1. Yes
     2. No
132. If yes, length of time:
134. In the past six months, have you been unable to pay medical bills (for either youself or a family member) that you MUST pay?

     1. Yes
     2. No
135. In the past six months, have you been unable to pay other bills that YOU must pay?

     1. Yes
     2. No
137. If yes, list bills you were unable to pay:
139. Do you spend time with your child(ren) on a regular basis, attend school activities, and/or consistently exercise your court-ordered parenting time?

     1. Yes
     2. No
141. In addition to your regular parenting time schedule, do you care for your children while the other parent is at work, at school, etc?

     1. Yes
     2. No
143. If yes, list how many hours you do this per week:
145. Do you provide non-money support (examples: transportation, clothing, etc.) to your children?

     1. Yes
     2. No
146. Would you be willing to take a finance or budget class?

     1. Yes
     2. No
148. Would you be willing to attend a jobs program?

     1. Yes
     2. No
149. Would you be willing to do volunteer work?

     1. Yes
     2. No
151. If yes, how many hours per week are you willing to volunteer?
155. MONTHLY INCOME INFORMATION (LIST GROSS AMOUNTS-BEFORE TAXES)
157. Income from job(s)
158. Worker's compensation
159. Unemployment
161. Pension
162. Child support received (for all cases)
163. Spousal support
165. Social Security (SSI, disability, retirement, etc)
166. Veterans Administration (VA) benefits
168. Settlement (legal settlement, insurance settlement, annuity)
169. Other income (describe source and monthly amount)
173. ASSET INFORMATION
175. Do you have a savings, checking, or other non-retirement account?

     1. Yes
     2. No
177. If yes, total amount in all accounts:
178. Date
180. Bank or financial institution name:
182. Do you have a retirement savings such as a 401(k)?

     1. Yes
     2. No
184. If yes, total amount in all retirement accounts:
185. Date
187. Bank or financial institution name:
189. Do you own or lease a car of truck?

     1. Yes
     2. No
190. If yes, number of cars/trucks owned or leased:
192. Do you have any of these items worth over $500?

     Check all that apply

     1. Computer/Tablet
     2. Boat
     3. Camper
     4. Motorcycle

     1. Snowmobile
     2. Jewelry
     3. Tools
194. Other
198. AVERAGE MONTHLY EXPENSES (your share or the amount you pay)
200. Rent/mortgage
201. Electric
202. Cable/satellite TV
203. Water
205. Natural gas/oil
206. Child Support
207. Phone (home/cell)
208. Credit cards
210. Medical bills
211. Car payments
212. Child care
213. Education
215. Spousal support
216. Insurance (care, life, medical, homeowners)
218. Other montly payment(s) (describe)
222. DEBTS
224. Total balance on credit card(s)
225. Date
227. Total balance on medical bills (self)
228. Date
230. Total balance on medical bills (family)
231. Date
233. Do you owe restitution as a result of a crime?

     1. Yes
     2. No
234. Do you owe fees, fines, and/or court costs?

     1. Yes
     2. No
236. If yes above, provide amount owed:
237. If yes above, provide amount owed:
239. Do you owe someone as a result of a court judgment?

     1. Yes
     2. No
241. If yes above, provide amount owed:
245. Please note that if any of your state-owed debt is discharged based on incorrect, incomplete, or false information you provided, the FOC may reinstate the debt forgiven (add it back to the total amount owed in support).
247. Please sign below to indicate that you believe the information you have provided on this form is correct and complete
249. 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.
251. Electronic Signature*
253. The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.
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255. 1. Receive an email copy of this form.
256. Email address

     This field is not part of the form submission.

257. Submit

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