To the Clerk:  For FOC office

The information obtained will be treated as confidential and shall not be used or released except for the purposes of
administering, enforcing, and complying with state and federal laws governing child support.
Contact person

Telephone no.

Date

Title

Employer name and address

Name of individual

ATTENTION:

Social security number

Our records indicate that you are the last-known employer for the individual stated above. This information may no longer 
be accurate. Our office may have previously issued an income withholding notice for this individual to your company. If you 
received a notice, please note that MCL 552.611 through MCL 552.614 require you to honor the notice.
Please  contact  the  friend  of  the  court  by  completing,  signing,  and  returning  this  form  within  7  days  of  receipt 
by  mail  or  facsimile  at  the  above  address  or  Fax  number.  Thank  you  for  your  cooperation;  your  assistance  is 
appreciated.

 The individual is currently employed here and has been since 

Date

If the individual is not employed with you, please check the items below that apply.

 

 was terminated 

 

 was laid off 

  on 

 .

 .

Date

City, state, zip                                                                                        Telephone no.

City, state, zip                                                                                        Telephone no.

 The individual was never employed here.
 was fired 
 The individual 

 quit 

 

 

 The individual is receiving unemployment from:  

                     

                     

 The individual is receiving benefits from: 

 Workers’ compensation 
 Disability
                     

 The individual may now be working at: 

 

 

 
 
 

 

 

Name

Address

Name

Address

Name

Address

Address

                     

                     

 

                     

 

                     

Approved, SCAO
Form FOC 22b, Rev. 6/22
Page 1 of 1

 The last-known address of the individual is: 

City, state, zip                                                                                        Telephone no.

Date

Name of person preparing form (type or print)

Signature of person preparing form

  

 

City, state, zip                                                                                        Telephone no.

 

 

 

Telephone no.

STATE OF MICHIGANJUDICIAL CIRCUITCOUNTYEMPLOYMENT STATUS DISCLOSURECASE NO. and JUDGEFriend of the court addressFax numberTelephone no.