Form Foc 22b - Employment Status Disclosure
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1Approved, SCAO
STATE OF MICHIGAN
CASE NO.
EMPLOYMENT STATUS DISCLOSURE
JUDICIAL CIRCUIT
COUNTY
Telephone no.
Fax number
Friend of the court address
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.
Contact person
Date
Title
Telephone no.
Employer name and address
Name of individual
Social security number
ATTENTION:
Our records indicate that you are the last-known employer for the individual stated above. This information may no longer be accurate.
Our office may have previously issued an income withholding notice for this individual to your company. If you received a notice, please
note that MCL 552.611 through MCL 552.614 require you to honor the notice.
Please contact the friend of the court by completing, signing, and returning this form within 7 days of receipt by mail or
facsimile at the above address or Fax number. Thank you for your cooperation; your assistance is appreciated.
The individual is currently employed here and has been since
.
Date
If the individual is not employed with you, please check the items below that apply.
The individual was never employed here.
The individual
quit
was fired
was terminated
was laid off
on
.
Date
The individual is receiving unemployment from:
Name
Address
(
)
City, state, zip
Telephone no.
The individual is receiving benefits from:
Name
Workers' compensation
Disability
Address
(
)
City, state, zip
Telephone no.
The individual may now be working at:
Name
Address
(
)
City, state, zip
Telephone no.
The last-known address of the individual is:
Address
(
)
City, state, zip
Telephone no.
Name of person preparing form (type or print)
Signature of person preparing form
Date
(
)
Telephone no.
EMPLOYMENT STATUS DISCLOSURE
FOC 22b (3/08)
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