Foc 39 Form PDF Details

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Question	Answer
Form Name	Foc 39 Form
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	foc39, request to reopen foc case wayne county mich, foc 39 form, case questionnaire

Form Preview Example

Approved, SCAO

STATE OF MICHIGAN JUDICIAL CIRCUIT

COUNTY

FRIEND OF THE COURT CASE QUESTIONNAIRE

(Page 1)

CASE NO.

Friend of the court address

Telephone no.

Plaintiff

Defendant

Complete this form and sign on page 4.

YOUR GENERAL INFORMATION

1. Your full name

2. Date of birth

Place of birth: city and state

4. Address

City

State

Zip

Home telephone

6. Work telephone

7. Social security number

8. Driver’s license no.

9. Professional license, type and no.

10. Cell phone

11. E-mail address

12. Sex

13. Eye color

14. Hair color

15. Height

16. Weight

17. Race

18. Scars, tattoos, etc.

19. Your father’s full name

20. Your mother’s full maiden name

21. Children in common with other parent in this case

Birthdate Gender

SSN Anticipated graduation date

No. of overnights you have w/child annually

22.Names of other biological/adopted minor children you support Birthdate Address

23.Are you pregnant? a. When is the child due? b. Is the other party in this case the biological parent of the expected child? 24. Are you presently married?

Yes

YOUR INCOME, MEDICAL, EDUCATIONAL, AND HEALTH INSURANCE INFORMATION

25. Your occupation

26. Your employer (if unemployed, name of last employer)

27. Employer’s address

City

State

Zip

28. Date hired

29.

Gross earnings per pay period (earnings before taxes)

30. Filing status

dependents claimed

weekly

biweekly

bimonthly

monthly

married

single

head of household

31.

Hourly pay rate (including shift premium and

32. Total regular hours worked per pay period

33. Average overtime hours for past 12

COLA)

months

34.

Second job

35. Employer

36. Employer’s address

City

State

Zip

37. Date hired

38. Gross earnings per pay period (earnings before taxes)
$	weekly	biweekly	bimonthly	monthly

39. Hourly pay rate

40.Average hours worked per pay period since hire date

41. If unemployed and not receiving unemployment or worker’s compensation benefits, or working part-time only, provide the following information:

Name of last full-time employer

Address of last full-time employer

Postition held at last place of full-time employment

Last day employed full-time

Length of time employed in last full-time position

Reason for leaving last full-time employment

Gross earings per pay period (earnings before taxes)
$	weekly	biweekly	bimonthly	monthly

FOC 39 (6/17) FRIEND OF THE COURT - CASE QUESTIONNAIRE (Page 1)

Approved, SCAO

STATE OF MICHIGAN JUDICIAL CIRCUIT

COUNTY

FRIEND OF THE COURT CASE QUESTIONNAIRE (Page 2)

CASE NO.

YOUR INCOME, MEDICAL, EDUCATIONAL, AND HEALTH INSURANCE INFORMATION (continued)

42. List MONTHLY income from all other sources, such as:
Commissions	Unemp. Benefits	Nat’l Guard & Res. Drill Pay
Bonuses	Strike Pay	Armed Services
Profit Sharing	SUB Pay	Allowance for Rent
Interest	Sick Benefits	Rental Income
Dividends	Workers’ Comp.	Spousal Support/Alimony
Annuities	Soc. Sec. Benefits	State Disability Assistance
Pensions/Longevity	VA Benefits	F I P
Deferred Comp./IRA	Disability Insurance	Supp. Security Income SSI
Trust Funds	GI Benefits	Other

43. Do you have any spousal support/alimony orders involving another person not a parent in this case?
If so, complete a. b. and c.	No	Yes, as payer		Yes, as recipient

a. Amount of order (do not include arrearages)	b. Type of order/Case no.		c. City, county, and state

44. Do any of the children listed on item 21 and 22 receive payments from the Social Security Administration?

Yes

Child’s

Name

Amount

(monthly)

Type of benefit (check one)

SSI	Dependent benefit

Source of dependent benefit (mother, father, stepparent)

45.Attach your four most recent paycheck stubs, or a statement from your employer(s) of wages and deductions, and year-to-date earnings, and a copy of your last federal and state income tax returns, including all schedules. If self-employed, also attach a copy of your three most recent business tax returns and/or corporation returns.

46.Do you have any medical conditions/restrictions that affect your ability to work?

	If yes, please explain medical condition/restriction:		Yes	No

47.	What is your educational background? (Check one)
	less than high school	High school graduate	Trade school graduate
	Associate’s degree	Bachelor’s degree	Graduate degree
48.	Medical insurance company name, address, telephone no.		Policy/Group number	Beginning date, if known

49.	Dental insurance company name, address, telephone no.		Policy/Group number	Beginning date, if known

50.	Optical insurance company name, address, telephone no.		Policy/Group number	Beginning date, if known

51. What dependent coverage is available to you without cost?

Medical

Dental

Optical

52. What dependent coverage is available by payment of an additional premium? (Specify cost per pay period.)

Medical

per

Dental

per

Optical

per

53. Individuals currently covered by your insurance

Name

Birthdate

Relationship

Medical ( )

Dental ( ) Optical ( )

FOC 39 (6/17) FRIEND OF THE COURT - CASE QUESTIONNAIRE (Page 2)

Approved, SCAO

STATE OF MICHIGAN		FRIEND OF THE COURT		CASE NO.
JUDICIAL CIRCUIT		FRIEND OF THE COURT
JUDICIAL CIRCUIT		CASE QUESTIONNAIRE
COUNTY		CASE QUESTIONNAIRE
COUNTY		(Page 3)
		(Page 3)


YOUR CHILD-CARE INFORMATION

54. Do you have child-care expenses for the minor children in this domestic relations case during any time of the year?				Yes	No
If yes, complete the following information.

Name of child-care provider			Names of children receiving child care

Number of weeks provided during last calendar year			Estimated number of weeks of child care provided in this calendar year

Current weekly child-care cost.	Amount of child-care credit received on last year’s federal I.R.S. tax return.

Does a federal or state agency or a public or private entity contribute all or a portion of the cost of child-care services? If yes, please explain.

55.	Check the reason(s) which explain why you need child care and estimate the number of hours child care is received for each.
	Reason	Estimated number of hours per week
	Work related
	Looking for employment
	Enrolled in educational program to
	improve employment opportunities

56.	If your reason for child care is education related, provide the following information.
	Name of educational institution	Total classroom hours per week	Educational goal	Projected graduation date
	Name of educational institution	Total classroom hours per week	Educational goal	Projected graduation date

ADDITIONAL INFORMATION

57. List any additional information about you or the other parent that would be useful to the court in making a support recommendation. For example: education, disability, or work history.

INFORMATION REGARDING THE OTHER PARENT IN THIS CASE (if known)

58.

Full name

59. Date of birth

60. Place of birth: city and state

61. Address

City

State

Zip

62. Home telephone

63. Work telephone

64.

Social security number

65. Driver’s license number

66. Professional license, type, and no.

67. Cell phone

68. E-mail address

69.

Sex

70. Eye color

71. Hair color

72. Height

73. Weight

74. Race

75. Scars, tattoos, etc.

76.

Father’s full name

77. Mother’s full maiden name

78.

Names of other biological/adopted minor children he/she supports

Birthdate

Address

79.

Is this party pregnant? a. When is the child due? b. Is the party in this case the biological parent of the expected child?

80. Is this party married?

Yes

81.

Occupation

82. Employer (if unemployed, name of last employer)

83.

Employer’s address

City

State

Zip

84. Date hired

85.

Gross earnings per pay period (earnings before taxes)

86. Average overtime hours for past 12 months.

FOC 39 (6/17) FRIEND OF THE COURT - CASE QUESTIONNAIRE (Page 3)

Approved, SCAO

STATE OF MICHIGAN JUDICIAL CIRCUIT

COUNTY

FRIEND OF THE COURT CASE QUESTIONNAIRE (Page 4)

CASE NO.

INFORMATION REGARDING THE OTHER PARENT IN THIS CASE (continued)

87.

Medical insurance company name, address, telephone no.

Policy/Group number

Beginning date, if known

88.

Dental insurance company name, address, telephone no.

Policy/Group number

Beginning date, if known

89.

Optical insurance company name, address, telephone no.

Policy/Group number

Beginning date, if known

90.

What dependent coverage is available to the other parent without cost?

Medical

Dental

Optical

91.

What dependent coverage is available by payment of an additional premium? (Specify cost per pay period.)

Medical

per

Dental

per

Optical

per

92.

Individuals currently covered by other parent’s insurance

Name

Birthdate

Relationship

Medical ( )

Dental ( ) Optical ( )

If you want friend of the court services, you must check the box below.

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

I declare that the information in this questionnaire is true to the best of my information, knowledge, and belief.

Date

Signature

Reminder List

•Have you signed this questionnaire?

•Have you completed item 21 regarding the number of overnights you have with the child annually? Failure to specify will result in the friend of the court estimating the number of overnights.

•Have you attached your four most recent paycheck stubs, or a statement from your employer(s) of wages and deductions and year-to-date earnings?

•Have you attached a copy of your last federal and state income tax returns, including all schedules, W-2s, and 1099s? If self-employed, also attach a copy of your three most recent business tax returns and/or corporation returns.

•Attach any additional information that may be useful to the friend of the court in making a support recommendation. Make sure you use enough postage to cover these additional items.

•Have you attached the Child Care Verification (form FOC 39e) if you are asking for reimbursement of child-care expenses?

•Make a copy of this form for your own records.

•Send the original form, completed and signed, to the friend of the court office.

FOC 39 (6/17) FRIEND OF THE COURT - CASE QUESTIONNAIRE (Page 4)

How to Edit Foc 39 Form Online for Free

Creating documents using this PDF editor is simpler as compared to most things. To change friend of the court case questionnaire forms template the form, there isn't anything you need to do - just continue with the actions down below:

Step 1: Select the orange "Get Form Now" button on this page.

Step 2: Now you are going to be within the file edit page. It's possible to add, customize, highlight, check, cross, insert or erase areas or words.

Complete the friend of the court case questionnaire forms template PDF and enter the material for every section:

Fill out the Children in common with other, Names of other biologicaladopted, Are you pregnant a When is the, Yes, Yes, Yes, YOUR INCOME MEDICAL EDUCATIONAL, Your employer if unemployed name, Employers address City State Zip, Date hired, Gross earnings per pay period, Hourly pay rate including shift, biweekly, bimonthly, and monthly areas with any details that is asked by the application.

Write the necessary details in bimonthly If unemployed and not, biweekly, weekly, monthly, Average hours worked per pay, Name of last fulltime employer, Address of last fulltime employer, Postition held at last place of, Last day employed fulltime, Length of time employed in last, Reason for leaving last fulltime, Gross earings per pay period, weekly, biweekly, and bimonthly field.

foc39 bimonthly If unemployed and not, biweekly, weekly, monthly, Average hours worked per pay, Name of last fulltime employer, Address of last fulltime employer, Postition held at last place of, Last day employed fulltime, Length of time employed in last, Reason for leaving last fulltime, Gross earings per pay period, weekly, biweekly, and bimonthly blanks to fill

Please be sure to record the rights and obligations of the parties in the STATE OF MICHIGAN, JUDICIAL CIRCUIT COUNTY, FRIEND OF THE COURT CASE, CASE NO, YOUR INCOME MEDICAL EDUCATIONAL, Commissions, Bonuses, Profit Sharing, Interest, Dividends, Annuities, PensionsLongevity, Deferred CompIRA, Trust Funds, and Unemp Benefits paragraph.

End by analyzing the following sections and completing them accordingly: Do any of the children listed on, Yes, Childs Name, Amount monthly, Type of benefit check one, SSI, Dependent benefit, Source of dependent benefit mother, Attach your four most recent, Yes, What is your educational, less than high school Associates, High school graduate Bachelors, Trade school graduate Graduate, and Medical insurance company name.

Do any of the children listed on, Yes, Childs Name, Amount monthly, Type of benefit check one, SSI, Dependent benefit, Source of dependent benefit mother, Attach your four most recent, Yes, What is your educational, less than high school Associates, High school graduate Bachelors, Trade school graduate Graduate, and Medical insurance company name in foc39

Step 3: Select the "Done" button. Next, you can transfer the PDF file - download it to your electronic device or send it by means of email.

Step 4: In order to prevent potential forthcoming problems, ensure that you obtain around two or three duplicates of every single document.

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