Verified Statement

616.776.3902 info@vandykenlaw.com
Stacy L. Van Dyken P.C. 161 Ottawa Avenue NW, Grand Rapids Michigan
Mon-Fri 9.00 - 17.00 Sat : 10.00 - 14.00 Sunday : Close

Approved, SCAO

Original - Friend of the court
1st copy - Plaintiff/Attorney
2nd copy - Defendant/Attorney

VERIFIED STATEMENT

STATE OF MICHIGAN

COUNTY

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JUDICIAL CIRCUIT

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CASE NO

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Parent's last name

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First name

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Middle name

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Any other names by which parent is or has been known

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Date of birth

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Social security number

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Driver's license number and state

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Mailing address and residence address (if different)

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E-mail address

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Eye color

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Hair color

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Height

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Weight

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Race

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Gender

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Scars, tattoos, etc

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Mobile telephone no

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Home telephone no

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Work telephone no

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Occupation

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Business/Employer's name and address

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Gross weekly income

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Did this parent apply for or receive public assistance? If yes, please specify kind and case number

yesno Invalid Input

Other parent's last name

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First name

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Middle name

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Any other names by which parent is or has been known

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Date of birth

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Social security number

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Driver's license number and state

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Mailing address and residence address (if different)

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E-mail address

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Eye color

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Hair color

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Height

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Weight

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Race

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Gender

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Scars, tattoos, etc

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Mobile telephone no

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Home telephone no

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Work telephone no

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Occupation

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Business/Employer's name and address

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Gross weekly income

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Did this parent apply for or receive public assistance? If yes, please specify kind and case number

yesno Invalid Input

Name and sex of minor child in case

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M/F

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Birth Date

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Age

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Soc Sec No

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Residential address

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Name and sex of other minor child of either party

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M/F

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Birth date

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Age

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Residential address

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Name of minor child

child1_name

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child2_name

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child3_name

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child4_name

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child5_name

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Name of policy holder

policyhoder1_name

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policyhoder2_name

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policyhoder3_name

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policyhoder4_name

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policyhoder5_name

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Name of insurance co./HMO

insurance1_name

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insurance2_name

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insurance3_name

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insurance4_name

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insurance5_name

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Policy/Certificate/Contract/Group no

policyno1

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policyno2

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policyno3

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policyno4

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policyno5

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Name(s) and address(es) of person(s) other than parties, if any, who may have custody of child(ren) during pendency of this case.

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I declare that the statements above are true to the best of my information, knowledge, and belief.

Date

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Signature

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If any of the public assistance information above changes before your judgment is entered, you are required to give the friend of the court written notice of the change. If you want child support services, complete form DHS 1201-D, available at your local friend of the court office or courts.mi.gov/Administration/ SCAO/Forms/courtforms/domesticrelations/generalfoc/dhs1201d.pdf

Captcha(*)

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FOC 23 (6/19) VERIFIED STATEMENT

MCR 3.206(C)

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161 Ottawa Avenue NW, Grand Rapids Michigan
616.776.3902
info@vandykenlaw.com

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