Verified Statement Form - State Of Michigan Sixth Judicial Circuit, Oakland County
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1STATE OF MICHIGAN
CASE NO.
SIXTH JUDICIAL CIRCUIT
VERIFIED STATEMENT
OAKLAND COUNTY
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 license number and state
6. Mailing address and residence address (if different)
E-Mail address
7. Eye color
8. Hair color
9. Height
10. Weight
11. Race
12.. Scars, tattoos, etc.
13. Home telephone number
14. Work telephone number
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 license number and state
26. Mailing address and residence address (if different)
E-Mail address
27. Eye color
28. Hair color
29. Height
30. Weight
31. Race
32.. Scars, tattoos, etc.
33. Home telephone number
34. Work telephone number
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 in case
b. Birth date
c. Age
d. Soc. Sec. No.
e. Residential address
41. a.
b. Birth date
c. Age
d. Soc. Sec. No.
e. Residential address
Other minor child of either party
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
request child support services available under title IV-D of the Social
I declare that the statements above are true to the best of
The Friend of the Court will not discriminate against any individual or group because of
I
my information and belief.
race, sex, religion, age, national origin, color marital status, political beliefs, or disability. If
Security Act
] YES (enforcement, locator, future modification).
[
you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act,
Answering “YES” allows Oakland County to qualify for federal funding.
you are invited to make your needs known at the Friend of the Court office.
PLEASE CHECK !
FOC (6/12)
Applicant’s Signature (Signature is required)
Date
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