Approved, SCAO

STATE OF MICHIGAN

JUDICIAL CIRCUIT
COUNTY

MOTION AND ORDER
FOR DISCLOSURE OF INCOME AND
HEALTH INSURANCE INFORMATION

Original - Court
1st copy - Friend of the court
2nd copy - Employer

CASE NO.

Court  address

Telephone  no.

Plaintiff's name, address, and telephone no.

v

Defendant's name, address, and telephone no.

TO:

Source of income
PERSONNEL DEPARTMENT:  CONFIDENTIAL

1. Pursuant to statute, the friend of the court is conducting an investigation.  Disclosure of income and available health

insurance coverage is essential to the completion of the investigation.

              MOTION

is employed by or receives income from the source of

3. THE FRIEND OF THE COURT REQUESTS that the court order the source of income to disclose all wages, earnings, salaries,

commissions, or other income, and all medical, dental, hospitalization, optical, or other health-related insurance coverage

income named above.

available to the income recipient.

2.

Date

1. Date of hearing:

Bar no.

2. IT IS ORDERED that the motion for disclosure of income and health insurance information is granted, and the source of

income named above shall make immediate and full disclosure as required by the friend of the court.

Friend of the court

ORDER

Judge:

Judge

CERTIFICATE OF MAILING

I certify that on this date I served a copy of this motion and order to the source of income by first-class mail addressed to the last-
known address as defined in MCR 3.203.

Date

Signature

MCL 552.505, MCL 552.517

FOC 21   (3/09)   MOTION AND ORDER FOR DISCLOSURE OF INCOME AND HEALTH INSURANCE INFORMATION