Free foc100.pmd - Michigan

Approved, SCAO

Original - Friend of the court Copies - All parties

STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY

DOMESTIC RELATIONS JUDGMENT INFORMATION, PAGE 1 TEMPORARY FINAL

CASE NO.

USE NOTE: Complete this form and file it with the friend of the court (do not file this form with the office of the clerk of the court) when the first temporary custody, parenting-time, or support order is entered and when submitting any final proposed judgment awarding custody, parenting time, or support. Mail a copy to each party and file proof of mailing with the court (may use form MC 302, Proof of Mailing).
(Check this box when information is being modified.)

Except as otherwise indicated below, all information previously provided is unchanged.

Date

Signature

Plaintiff Information
Name Address

Defendant Information
Name Address

Social security number

Telephone number

Social security number

Telephone number

Employer name, address, telephone number, and FEIN (if known)

Employer name, address, telephone number, and FEIN (if known)

Driver's license number and state Occupational license number(s), type(s), issuing state(s), and date(s)

Driver's license number and state Occupational license number(s), type(s), issuing state(s), and date(s)

CUSTODY PROVISIONS Child's name

sole, plaintiff = P sole, defendant = D

joint = J

other = O (must identify)

Social security Date of birth number

Physical custody
P, D, J, O

Child's primary residence address

Legal custody
P, D, J, O

SUPPORT PROVISIONS Support provisions are stated in the Uniform Support Order. Medical Support provisions are stated on page 2 of this form.
FOC 100 (3/09)

DOMESTIC RELATIONS JUDGMENT INFORMATION, PAGE 1

MCR 3.211(F)

Approved, SCAO

Original - Friend of the court Copies - All parties

STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY

DOMESTIC RELATIONS JUDGMENT INFORMATION, PAGE 2 TEMPORARY FINAL

CASE NO.

MEDICAL SUPPORT PROVISIONS: List the name of each insurance provider for the plaintiff and the defendant. Then enter the name of each child in this case who is covered by that provider and the type of coverage provided. Plaintiff's Insurance Coverage
Name and address of provider Policy no. Cert. no. Child(ren)'s name(s) Medical Dental Optical Other

Defendant's Insurance Coverage
Name and address of provider Policy no. Cert. no. Child(ren)'s name(s) Medical Dental Optical Other

FOC 100 (3/09)

DOMESTIC RELATIONS JUDGMENT INFORMATION, PAGE 2

MCR 3.211(F)