Employers Disclosure Of Income And Health Insurance Information
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3Approved, SCAO
CASE NO.
STATE OF MICHIGAN
EMPLOYER'S DISCLOSURE OF INCOME AND
JUDICIAL CIRCUIT
HEALTH INSURANCE INFORMATION
COUNTY
Friend of the court address
Telephone no.
The information obtained will be treated as confidential and shall not be used or released except for the purposes of administering,
enforcing, and complying with state and federal laws governing child support.
Title
Telephone no.
Name of contact (type or print)
Date
1. Employee name
2. Address
3. Social security number
4. Employer name
5. Employer federal identification no.
6. Employer address
Complete items 7, 8, and 9 if insurance is available to employee.
7. Medical insurance company name, address, telephone no. Policy number 8. Dental insurance company name, address, telephone no.
Policy number
9. Optical insurance company name, address, telephone no. Policy number 10. What dependent coverage is automatically available?
Medical
Dental
Optical
11. What dependent coverage is available by payment of an additional premium? Specify cost to employee
per individual
per family
Medical
per
Dental
per
Optical
per
12. What dependents of employee are covered?
Effective Date of Coverage
Name
DOB
Relationship
Medical
Dental
Optical
13. Hourly base pay 14. Shift premium
15. COLA
16. Avg. overtime
17. W-4 Exemp. 18. Reg. work hours 19. Pay period (weekly, etc.)
$
/week
/week
20. No. weeks paid this yr. 21. Date hired
22. Date of term. (if appl.) 23. Reason for leaving
24. Is this person receiving
Yes
unemployment benefits?
No
Calculate year to date figures as of last pay period.
25.
Reg. Earnings
Deferred
Commissions
Pension and
Other
(incl. shift prem.
INCOME
Overtime
Profit Sharing
Gross
income in
and Bonuses
Longevity
(explain)
and COLA)
addition to gross
Year to Date
Last Calendar
Year
26.
Workers
OTHER
Disability
Sick Pay
SUB Pay
Comp.
INCOME
Disability carrier
Year to Date
Last Calendar
Worker's compensation carrier
Year
27.
Mandatory
Alimony
State
Federal
Local
Mandatory Withholding
WITHHOLDING
F.I.C.A.
Professional
and Child
Income Tax
Income Tax
(explain)
Income Tax
or Union Dues
Support
Year to Date
Last Calendar
Year
Sign and return to the friend of the court address listed above. Use other side if necessary. See the notice on the other side.
Date
Name and signature of person preparing form
Telephone no.
EMPLOYER'S DISCLOSURE OF INCOME AND HEALTH INSURANCE INFORMATION
FOC 22 (3/08)
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