Verified Statement And Application For Iv-D Services
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1Original - Friend of the court
1st copy - Plaintiff/Attorney
Approved, SCAO
2nd copy - Defendant/Attorney
STATE OF MICHIGAN
CASE NO.
JUDICIAL CIRCUIT
VERIFIED STATEMENT AND
COUNTY
APPLICATION FOR IV-D SERVICES
1. Mother's last name
First name
Middle name
2. Any other names by which mother is or has been known
3. Date of birth
4. Social security number
5. Driver's license number and state
6. Mailing address and residence address (if different)
7. Eye color
8. Hair color
9. Height
10. Weight
11. Race
12. Scars, tattoos, etc.
13. Home telephone no.
14. Work telephone no.
15. Maiden name
16. Occupation
17. Business/Employer's name and address
18. Gross weekly income
19. Has mother applied for or does she receive public assistance? If yes, please specify kind. 20. DHS case number
Yes
No
21. Father's last name
First name
Middle name
22. Any other names by which father is or has been known
23. Date of birth
24. Social security number
25. Driver's license number and state
26. Mailing address and residence address (if different)
27. Eye color
28. Hair color
29. Height
30. Weight
31. Race
32. Scars, tattoos, etc.
33. Home telephone no.
34. Work telephone no.
35. Occupation
36. Business/Employer's name and address
37. Gross weekly income
38. Has father applied for or does he receive public assistance? If yes, please specify kind. 39. DHS case number
Yes
No
40. a. Name of Minor Child Involved in Case
b. Birth Date c. Age
d. Soc. Sec. No.
e. Residential Address
41. a. Name of Other Minor Child of Either Party b. Birth Date c. Age
d. Residential Address
42. Health care coverage available for each minor child
a. Name of Minor Child
b. Name of Policy Holder
c. Name of Insurance Co./HMO
d. Policy/Certificate/Contract No.
43. Names and addresses of person(s) other than parties, if any, who may have custody of child(ren) during pendency of this case
If any of the public assistance information above changes before your judgment is entered, you are required to give the friend of
the court written notice of the change.
I request support services under Title IV-D of the Social Security Act.
I declare that the statements above are true to the best of my information, knowledge, and belief.
Date
Signature
VERIFIED STATEMENT AND APPLICATION FOR IV-D SERVICES
FOC 23 (3/08)
MCR 3.206(B)
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