Approved, SCAO
Original - Friend of the court
1st copy - Plaintiff/Attorney
2nd copy - Defendant/Attorney
VERIFIED STATEMENT

STATE OF MICHIGAN

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Name of minor child
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Name of policy holder
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Name of insurance co./HMO
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Policy/Certificate/Contract/Group no
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I declare that the statements above are true to the best of my information, knowledge, and belief. 

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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
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FOC 23 (6/19) VERIFIED STATEMENT
MCR 3.206(C)

KEEP IN TOUCH

LOCATION/DIRECTIONS

  Waters Building Grand Rapids Michigan, Attorney Stacy Van Dyken

At the Grand Rapids law office of Stacy L. Van Dyken, P.C., we conveniently serve clients throughout West Michigan, including the cities of Holland, Muskegon, and Grand Haven and throughout Kent County, Ottawa County, Allegan County, Barry County, Newaygo County, Montcalm County, and Ionia County.