Prisoner Information Addendum Form - State Of Michigan Judicial Circuit
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1Original - Court
Approved, SCAO
Copy - Friend of the court
STATE OF MICHIGAN
CASE NO.
JUDICIAL CIRCUIT
PRISONER INFORMATION ADDENDUM
COUNTY
Plaintiff's name
Defendant's name
v
Attorney:
Attorney:
GENERAL INFORMATION
Full name (last, first)
Date of birth
Offender number
Address
City
State
Zip
Date current sentence started Earliest release date
Contacted the friend of the court to modify child support during this period of my incarceration.
Yes
Date of contact:____________________________
No
Dependent children in this case (name[s] and date[s] of birth)
1.
2.
3.
4.
Number of dependent children not in this case:
INCOME/ASSET, WORK, AND EXPENSE INFORMATION
Employed by
Name of employer
Prison at $___________ week
___________________________________________
at $ ________ hour for _____ hours per pay period
Other income sources:
$ _________ profit sharing
$ _________ interest
$ _________ dividends
$ _________ royalties
$ _________ annuities
$ _________ pension
$ _________ deferred compensation
$ _________ _______________________
$ _________ trust fund
$ _________ rental income
$ _________ Individual Retirement Account
$ _________ _______________________
Bank accounts
Land (estimated value of all land)
$ _________ checking
$ _________ savings
$ _________ ___________________________
$ _________________________
Vehicles (estimated value and type of vehicle)
$ _________ ___________________________
$ _________ _______________________
$ _________ _______________________________
Name and address of last employer
Dates employed by above employer
Reason for leaving above employer
from:__________________________
to: ___________________________
Earnings paid by above employer each pay period before taxes
Medical conditions that affect ability to work (specify)
$ _____________ every ______________________________
Educational level
Less than high school
High school graduate/GED
Trade school
Associate degree
Bachelor degree
Graduate degree
Spousal support orders from other cases
Case number
City
County
State
$ _________ every __________________
__________________________________________________________________________________
$ _________ every __________________
__________________________________________________________________________________
Rent
Vehicle payment
Mortgage payment
Other
$ _________ every ____________
$ _________ every ____________
$ _________ every ____________
$ _________ every __________
INFORMATION AS TO CHILD'S CUSTODIAN (if known)
Full name of custodian (last, first)
Date of birth of custodian
Last known address of custodian
Last known telephone number of custodian
Are you currently incarcerated for a crime against the child(ren) in this case, their parent, and/or their custodian?
Yes
No
I declare that the statements above are true to the best of my information, knowledge, and belief.
Date
Signature
PRISONER INFORMATION ADDENDUM
FOC 118 (5/10)
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