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Here is the text we could read:

CHILD-CARE VERIFICATION

Original - Friend of the court
Additional copies as needed

CASE NO.

Telephone  no.

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.

Approved, SCAO

STATE OF MICHIGAN

JUDICIAL CIRCUIT
COUNTY

Friend  of  the  court    address

PARENT INFORMATION

Name

Name(s) and age(s) of child(ren) involved in this case

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 child(ren) named above.

Name of provider

Address

City

State

Zip

County

Area  code  and

Telephone no.

Name and Age of Child

School  Year  Rates

Average  No.  of  Hours/Week Hourly Rate

Total Weekly Rate

Name and Age of Child

Summer  Season  Rates

Average  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?
If yes, please explain.

Yes

No

Does a federal or state agency or a public or private entity contribute all or a portion of the cost of child-care services?
If yes, please provide the agency name and amount contributed.

Yes

No

The information above 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 information provided above is true, accurate, and complete.

Date

Signature and title of provider

FOC 39e  (3/14)   CHILD-CARE VERIFICATION

Child-Care Verification

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): 1
Fields(s): 51
Average fields per page: 51
Reading Level: Grade 7
LIST Grouping(s): FA-00-00-00-00, GO-00-00-00-00.

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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.

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

Child-Care Verification

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