Here is the text we could read:
To the Clerk: For FOC office
NOTICE TO EMPLOYER
Under Michigan law, you are required to provide information according to MCL 552.518. Return this completed form to the
friend of the court at the above address. Complete both pages.
1. Employee name
2. Employee social security number 3. Employee telephone no.
6. Employer federal identification no.
8. Hourly base pay
9. Shift premium
10. COLA
11. Avg. overtime
12. W-4 Exemp. 13. Reg. work hours 14. Pay period (weekly, etc.)
15. No. weeks paid this yr.
16. Date hired
17. Date of term. (if appl.)
18. Reason for leaving
$
/week
/week
19. Is this person receiving
unemployment benefits?
Yes
No
Calculate year-to-date figures as of last pay period.
20.
INCOME
Reg. Earnings
(incl. shift prem.
and COLA)
Overtime
Commissions
and Bonuses
Pension and
Longevity
Profit Sharing
Gross
Other
(explain)
Deferred
income in
addition to
gross
Mandatory
Employee
Voluntary
Employee
Disability
Sick Pay
SUB Pay
Workers
Comp.
Disability carrier
Worker’s compensation carrier
23.
WITHHOLDING
Federal
Income Tax
F.I.C.A.
State
Income Tax
Local
Income Tax
Mandatory
Professional
or Union Dues
Alimony
and Child
Support
Mandatory Withholding
(explain)
24. Check all that apply
Employer offers a medical flexible spending account.
Dependent insurance not offered to employees.
Dependent insurance
optical
(Attach information regarding dependent coverages and cost.)
(Attach information regarding dependent coverages and cost.)
medical
dental
Employee will be eligible for dependent insurance. Date available:
Employee has enrolled for dependent insurance. (Complete items 25 through 30. If you need additional space, use the space below.)
is offered to the employee but the employee has not enrolled.
4. Employee address
5. Employer name
7. Employer address
Year to Date
Last Calendar
Year
21.
RETIREMENT
CONTRIBUTIONS
22.
Year to Date
Last Calendar
Year
OTHER
INCOME
Year to Date
Last Calendar
Year
Year to Date
Last Calendar
Year
Approved, SCAO
Form FOC 22, Rev. 6/22
MCL 552.518
Page 1 of 2
STATE OF MICHIGANJUDICIAL CIRCUITCOUNTYEMPLOYER’S DISCLOSURE OF HEALTHINSURANCE AND/OR INCOMEINFORMATIONCASE NO. and JUDGEFriend of the court address Telephone no. Employer’s Disclosure of Health Insurance and/or Income Information
Page 2 of 2
(6/22)
Case No.
25. Medical insurance company name, address, telephone no.
26. Dental insurance company name, address, telephone no.
Policy no. and Group no.
Policy no. and Group no.
27. Optical insurance company name, address, telephone no.
28. Other insurance (i.e. prescription, mental health)
Policy no. and Group no.
29. What dependent coverage is offered? Specify cost to employee
employee only
individual plus one
per family
Medical $
per
Dental $
per
Optical $
per
30. What dependents of employee are covered?
Name DOB Relationship Medical Dental Optical
Effective Date of Coverage
Date
Name of person preparing form (type or print)
Telephone no.
The information obtained from this disclosure form will be treated as confidential and will not be used or released except for
purposes of administering, enforcing, and complying with state and federal laws governing child support.
Name of contact (type or print)
Title
Telephone no.
Date
Use this space for any necessary explanations.
FOC 22, Employer's Disclosure of Health Insurance and/or Income Information
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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.
employee_name was 1 Employee name (0.61 conf)employee_social_number was 2 Employee social security number (0.41 conf)employee_telephone was 3 Employee telephone no (0.43 conf)employee_address was 4 Employee address (0.36 conf)employer_name was 5 Employer name (0.40 conf)employer_federal was 6 Employer federal identification no (0.45 conf)employer_address was 7 Employer address (0.38 conf)circuit was Circuit (0.33 conf)county was County (0.39 conf)judge was Judge (0.39 conf)telephone was Telephone no (0.44 conf)friend_court_address was Friend of the court address (0.41 conf)
We've done our best to group similar variables togther to avoid overwhelming the user.
Suggested Screen 0:
employee_nameemployee_social_numberemployee_telephoneemployee_addressemployer_nameemployer_federalemployer_addressjudgefriend_court_address
Suggested Screen 1:
Suggested Screen 2:
Suggested Screen 3:
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