Child Care Verification
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1Original - Court
Approved, SCAO
Additional copies as needed
STATE OF MICHIGAN
CASE NO.
JUDICIAL CIRCUIT
CHILD CARE VERIFICATION
COUNTY
Court address
Court telephone no.
PARENT INFORMATION
Complete the top portion of this form and have your child care provider complete the remainder.
It is your responsibility to return the completed form to the Friend of the Court.
Name
Name(s) and age(s) of child(ren) involved in this case
Are you receiving financial assistance for child care from any Federal or State agency:
Yes
No
If yes, please state the agency and the amount your are receiving.
CHILD CARE PROVIDER INFORMATION
Please attach a schedule of your most recent child care rates.
The Child Care Provider must complete the remainder of this form for the above named child(ren).
Name of provider
Address
City
State
Zip
County
Area Code and
Telephone no.
Name and Age of Child
School Year Rates
Avg. No. of Hours/Week
Hourly Rate
Total Weekly Rate
Name and Age of Child
Summer Season Rates
Avg. No. of Hours/Week
Hourly Rate
Total Weekly Rate
Do you require payment for services even when children are absent to guarantee a position in your center?
Yes
No
If yes, please explain:
Does a Federal or State agency contribute all or a portion of these child care services?
Yes
No
If yes, please provide agency name and amount contributed.
The above information is provided to enable the Friend of the Court to accurately report child care costs in making a child
support recommendation. I certify that the above information is true, accurate, and complete.
Date
Signature and title of provider
CHILD CARE VERIFICATION
FOC 39e (9/88)
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