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Here is the text we could read:

To the Clerk: For FOC office

Information about you:
1. Last name First name Middle name

2. Any other names by which you have been known

3. Date of birth

4. Social security number

5. Driver’s license number and state

6. Mailing address and residence address (if different)

7. E-mail address

8. Eye color

9. Hair color

10. Height

11. Weight

12. Race

13. Gender

14. Scars, tattoos, etc.

15. Mobile telephone no.

16. Home telephone no.

17. Work telephone no.

18. Occupation

19. Business/Employer’s name and address

20. Gross weekly income

21. Did you apply for or receive public assistance? If yes, please specify kind and case number.

Yes

22. Any other country(ies) of citizenship:

23. Foreign/international identifying number(s) and source(s) (driver’s license, passport, social/tax no., etc.)

Information about the other parent in this case:
24. Last name First name Middle name

25. Any other names by which parent has been known

26. Date of birth

27. Social security number

28. Driver’s license number and state

29. Mailing address and residence address (if different)

30. E-mail address

31. Eye color

32. Hair color

33. Height

34. Weight

35. Race

36. Gender

37. Scars, tattoos, etc.

38. Mobile telephone no.

39. Home telephone no.

40. Work telephone no.

41. Occupation

42. Business/Employer’s name and address

43. Gross weekly income

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

Unsure

Yes

45. Any other country(ies) of citizenship:

46. Foreign/international identifying number(s) and source(s) (driver’s license, passport, social/tax no., etc.)

Approved, SCAO
Form FOC 23, Rev. 6/22
MCR 3.206(C)
Page 1 of 2

Distribute form to:
Friend of the Court
Plaintiff/Attorney
Defendant/Attorney

STATE OF MICHIGANJUDICIAL CIRCUITCOUNTYVERIFIED STATEMENTCASE NO. and JUDGEFriend of the court addressTelephone no.Verified Statement
Page 2 of 2

(6/22)

Case No.

Information about the minor child(ren):
47. a. Name and sex of minor child in case M/F b. Birth date

c. Age

d. Soc. sec. no. e. Residential address

48. a. Name and sex of other minor child of either party M/F b. Birth date c. Age d. Residential address

49. Health care coverage available for each minor child

a. Name of minor child

b. Name of policy holder

c. Name of insurance Co./HMO

d. Policy/Certificate/Contract/Group No.

50. 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.

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

Date

Signature

You are required to notify friend of the court, in writing, if any of your public assistance information changes before your judgment is entered. If you want
child support services, complete form DHS-1201D. DHS-1201D is available online at https://www.courts.michigan.gov/49752a/siteassets/forms/scao-
approved/dhs1201d.pdf. Or you may request a copy from your local friend of the court office.

FOC 23, Verified Statement

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the Michigan state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from www.courts.michigan.gov/Domestic-Relations (2023-03)
Page(s): 2
Fields(s): 118
Average fields per page: 59
Reading Level: Grade 6
LIST Grouping(s): Unknown

Use our Rate My PDF tool to learn more. Go beyond the above insights and learn more about this or any pdf form at RateMyPDF.com, includes: counts of difficult words used, passive voice decetion, and suggestions for how to make the form more usable.

Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

Here are the fields we could identify.

circuit was Circuit (0.53 conf)
county was County (0.39 conf)
judge was Judge (0.39 conf)
friend_court_address was Friend of the court address (0.41 conf)
telephone was Telephone no (0.44 conf)
last_name_first_middle__1 was 1 Last name First name Middle name (0.34 conf)
names_filing_party_known was 2 Any other names by which youthe filing party have been known (0.44 conf)
date_birth__1 was 3 Date of birth (0.35 conf)
social_security_number__1 was 4 Social security number (0.39 conf)
drivers_license_number_state__1 was 5 Drivers license number and state (0.51 conf)
address_residence_different__1 was 6 Mailing address and residence address if different (0.37 conf)
email_address__1 was 7 Email address (0.41 conf)
eye_color__1 was 8 Eye color (0.33 conf)
hair_color__1 was 9 Hair color (0.33 conf)
height__1 was 10 Height (0.34 conf)
weight__1 was 11 Weight (0.34 conf)
race__1 was 12 Race (0.35 conf)
gender__1 was 13 Gender (0.37 conf)
scars_tattoos_etc__1 was 14 Scars tattoos etc (0.36 conf)
mobile_telephone was 15 Mobile telephone no (0.42 conf)
home_telephone__1 was 16 Home telephone no (0.47 conf)
work_telephone__1 was 17 Work telephone no (0.52 conf)
occupation__1 was 18 Occupation (0.38 conf)
business_employers_address__1 was 19 BusinessEmployers name and address (0.42 conf)
gross_weekly_income__1 was 20 Gross weekly income (0.30 conf)
undefined__1 was undefined (0.38 conf)
undefined__2 was undefined_2 (0.39 conf)
receive_public_assistance_number was 21 Did youthe filing party apply for or receive public assistance If yes please specify kind and case number Yes No (0.49 conf)
countryies_citizenship__1 was 22 Any other countryies of citizenship (0.35 conf)
identifying_numbers_etc__1 was 23 Foreigninternational identifying numbers and sources drivers license passport socialtax no etc (0.42 conf)
last_name_first_middle__2 was 24 Last name First name Middle name (0.34 conf)
names_parent_known was 25 Any other names by which parent has been known (0.42 conf)
date_birth__2 was 26 Date of birth (0.35 conf)
social_security_number__2 was 27 Social security number (0.39 conf)
drivers_license_number_state__2 was 28 Drivers license number and state (0.51 conf)
address_residence_different__2 was 29 Mailing address and residence address if different (0.37 conf)
email_address__2 was 30 Email address (0.41 conf)
eye_color__2 was 31 Eye color (0.33 conf)
hair_color__2 was 32 Hair color (0.33 conf)
height__2 was 33 Height (0.34 conf)
weight__2 was 34 Weight (0.34 conf)
race__2 was 35 Race (0.35 conf)
gender__2 was 36 Gender (0.37 conf)
scars_tattoos_etc__2 was 37 Scars tattoos etc (0.41 conf)
home_telephone__2 was 38 Home telephone no (0.47 conf)
home_telephone__3 was 39 Home telephone no (0.47 conf)
work_telephone__2 was 40 Work telephone no (0.52 conf)
occupation__2 was 41 Occupation (0.36 conf)
business_employers_address__2 was 42 BusinessEmployers name and address (0.39 conf)
gross_weekly_income__2 was 43 Gross weekly income (0.34 conf)
receive_public_assistance_kind was 44 Did this parent apply for or receive public assistance If yes please specify kind and case number (0.49 conf)
countryies_citizenship__2 was 45 Any other countryies of citizenship (0.35 conf)
identifying_numbers_etc__2 was 46 Foreigninternational identifying numbers and sources driver s license passport socialtax no etc (0.38 conf)
no was No (0.45 conf)
checkbox_unsure was checkbox-unsure (0.31 conf)
name_sex_minor_child_case_row__1 was 47 a Name and sex of minor child in case MFRow1 (0.33 conf)
name_sex_minor_child_case_row__2 was 47 a Name and sex of minor child in case MFRow1_2 (0.34 conf)
b_birth_date_row__1 was b Birth dateRow1 (0.38 conf)
c_age_row__1 was c AgeRow1 (0.27 conf)
soc_sec_row__1 was d Soc sec noRow1 (0.34 conf)
e_residential_address_row__1 was e Residential addressRow1 (0.45 conf)
name_sex_minor_child_case_row__3 was 47 a Name and sex of minor child in case MFRow2 (0.33 conf)
name_sex_minor_child_case_row__4 was 47 a Name and sex of minor child in case MFRow2_2 (0.34 conf)
b_birth_date_row__2 was b Birth dateRow2 (0.38 conf)
c_age_row__2 was c AgeRow2 (0.27 conf)
soc_sec_row__2 was d Soc sec noRow2 (0.34 conf)
e_residential_address_row__2 was e Residential addressRow2 (0.45 conf)
name_sex_minor_child_case_row__5 was 47 a Name and sex of minor child in case MFRow3 (0.33 conf)
name_sex_minor_child_case_row__6 was 47 a Name and sex of minor child in case MFRow3_2 (0.34 conf)
b_birth_date_row__3 was b Birth dateRow3 (0.38 conf)
c_age_row__3 was c AgeRow3 (0.27 conf)
soc_sec_row__3 was d Soc sec noRow3 (0.34 conf)
e_residential_address_row__3 was e Residential addressRow3 (0.45 conf)
name_sex_minor_child_case_row__7 was 47 a Name and sex of minor child in case MFRow4 (0.33 conf)
name_sex_minor_child_case_row__8 was 47 a Name and sex of minor child in case MFRow4_2 (0.34 conf)
b_birth_date_row__4 was b Birth dateRow4 (0.38 conf)
c_age_row__4 was c AgeRow4 (0.27 conf)
soc_sec_row__4 was d Soc sec noRow4 (0.34 conf)
e_residential_address_row__4 was e Residential addressRow4 (0.45 conf)
name_sex_minor_child_case_row__9 was 47 a Name and sex of minor child in case MFRow5 (0.33 conf)
name_sex_minor_child_case_row__10 was 47 a Name and sex of minor child in case MFRow5_2 (0.34 conf)
b_birth_date_row__5 was b Birth dateRow5 (0.38 conf)
c_age_row__5 was c AgeRow5 (0.27 conf)
soc_sec_row__5 was d Soc sec noRow5 (0.34 conf)
e_residential_address_row__5 was e Residential addressRow5 (0.45 conf)
name_minor_either_party_row__1 was 48 a Name of other minor child of either partyRow1 (0.38 conf)
name_sex_minor_child_case_row__11 was 48 a Name and sex of minor child in case MFRow4_2 (0.34 conf)
b_birth_date_row__6 was b Birth dateRow1_2 (0.39 conf)
c_age_row__6 was 48.c AgeRow1 (0.36 conf)
c_age_row__7 was 48.c AgeRow2 (0.36 conf)
residential_address_row__1 was d Residential addressRow1 (0.40 conf)
name_minor_either_party_row__2 was 48 a Name of other minor child of either partyRow2 (0.38 conf)
name_sex_minor_child_case_row__12 was 48 a Name and sex of minor child in case MFRow5_2 (0.34 conf)
b_birth_date_row__7 was b Birth dateRow2_2 (0.39 conf)
residential_address_row__2 was d Residential addressRow2 (0.40 conf)
name_minor_child_row__1 was a Name of minor childRow1 (0.39 conf)
b_name_policy_holder_row__1 was b Name of policy holderRow1 (0.32 conf)
c_name_insurance_co_hmo_row__1 was c Name of insurance CoHMORow1 (0.43 conf)
policy_certificate_group__1 was d PolicyCertificateContractGroup NoRow1 (0.42 conf)
name_minor_child_row__2 was a Name of minor childRow2 (0.39 conf)
b_name_policy_holder_row__2 was b Name of policy holderRow2 (0.32 conf)
c_name_insurance_co_hmo_row__2 was c Name of insurance CoHMORow2 (0.43 conf)
policy_certificate_group__2 was d PolicyCertificateContractGroup NoRow2 (0.42 conf)
name_minor_child_row__3 was a Name of minor childRow3 (0.39 conf)
b_name_policy_holder_row__3 was b Name of policy holderRow3 (0.32 conf)
c_name_insurance_co_hmo_row__3 was c Name of insurance CoHMORow3 (0.43 conf)
policy_certificate_group__3 was d PolicyCertificateContractGroup NoRow3 (0.42 conf)
name_minor_child_row__4 was a Name of minor childRow4 (0.39 conf)
b_name_policy_holder_row__4 was b Name of policy holderRow4 (0.32 conf)
c_name_insurance_co_hmo_row__4 was c Name of insurance CoHMORow4 (0.43 conf)
policy_certificate_group__4 was d PolicyCertificateContractGroup NoRow4 (0.42 conf)
name_minor_child_row__5 was a Name of minor childRow5 (0.39 conf)
b_name_policy_holder_row__5 was b Name of policy holderRow5 (0.32 conf)
c_name_insurance_co_hmo_row__5 was c Name of insurance CoHMORow5 (0.43 conf)
policy_certificate_group__5 was d PolicyCertificateContractGroup NoRow5 (0.42 conf)
addresses_custody_case was 50 Names and addresses of persons other than parties if any who may have custody of children during pendency of this case (0.39 conf)
signature_date was Date (1.00 conf)
text was Text6 (0.35 conf)

We've done our best to group similar variables togther to avoid overwhelming the user.

Suggested Screen 0:

circuit
county
judge
friend_court_address
telephone
last_name_first_middle__1
names_filing_party_known
date_birth__1
social_security_number__1
drivers_license_number_state__1
address_residence_different__1
email_address__1
eye_color__1
hair_color__1
height__1
weight__1
race__1
gender__1
scars_tattoos_etc__1
mobile_telephone
home_telephone__1
work_telephone__1
occupation__1
business_employers_address__1
gross_weekly_income__1
undefined__1
undefined__2
receive_public_assistance_number
countryies_citizenship__1
identifying_numbers_etc__1
last_name_first_middle__2
names_parent_known
date_birth__2
social_security_number__2
drivers_license_number_state__2
address_residence_different__2
email_address__2
eye_color__2
hair_color__2
height__2
weight__2
race__2
gender__2
scars_tattoos_etc__2
home_telephone__2
home_telephone__3
work_telephone__2
occupation__2
business_employers_address__2
gross_weekly_income__2
receive_public_assistance_kind
countryies_citizenship__2
identifying_numbers_etc__2
no
checkbox_unsure
name_sex_minor_child_case_row__1
name_sex_minor_child_case_row__2
b_birth_date_row__1
c_age_row__1
soc_sec_row__1
e_residential_address_row__1
name_sex_minor_child_case_row__3
name_sex_minor_child_case_row__4
b_birth_date_row__2
c_age_row__2
soc_sec_row__2
e_residential_address_row__2
name_sex_minor_child_case_row__5
name_sex_minor_child_case_row__6
b_birth_date_row__3
c_age_row__3
soc_sec_row__3
e_residential_address_row__3
name_sex_minor_child_case_row__7
name_sex_minor_child_case_row__8
b_birth_date_row__4
c_age_row__4
soc_sec_row__4
e_residential_address_row__4
name_sex_minor_child_case_row__9
name_sex_minor_child_case_row__10
b_birth_date_row__5
c_age_row__5
soc_sec_row__5
e_residential_address_row__5
name_minor_either_party_row__1
name_sex_minor_child_case_row__11
b_birth_date_row__6
c_age_row__6
c_age_row__7
residential_address_row__1
name_minor_either_party_row__2
name_sex_minor_child_case_row__12
b_birth_date_row__7
residential_address_row__2
name_minor_child_row__1
b_name_policy_holder_row__1
c_name_insurance_co_hmo_row__1
policy_certificate_group__1
name_minor_child_row__2
b_name_policy_holder_row__2
c_name_insurance_co_hmo_row__2
policy_certificate_group__2
name_minor_child_row__3
b_name_policy_holder_row__3
c_name_insurance_co_hmo_row__3
policy_certificate_group__3
name_minor_child_row__4
b_name_policy_holder_row__4
c_name_insurance_co_hmo_row__4
policy_certificate_group__4
name_minor_child_row__5
b_name_policy_holder_row__5
c_name_insurance_co_hmo_row__5
policy_certificate_group__5
addresses_custody_case
signature_date
text

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The Legal Innovation & Technology Lab's Form Explorer Beta @ Suffolk Law School Last updated 2023-04-02

FOC 23, Verified Statement

About This Form:

Identified Data Fields:

Create an Interactive Version of this Form:

The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02