Fill and Sign the Michigan Verified Statement Form

Approved, SCAO Original – Court 1 st copy – Plaintiff 2 nd copy – Defendant STATE OF MICHIGAN VERIFIED STATEMENT CASE NO.       JUDICIAL CIRCUIT             COUNTY 1. Mother’s last name First name Middle name 2. Any other names by which mother is or has 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. Eye color 8. Hair color 9. Height 10. Weight 11. Race 12. Scars, tattoos, etc.                                     13. Home telephone number 14. Work telephone number 15. Maiden name 16. Occupation                         17. Business/Employer’s name and address 18. Gross weekly income             19. Has wife applied for or does she receive public assistance? If yes, please specify kind. 20. AFCC and recipient identification numbers Yes No             21. Father’s last name First name Middle name 22. Any other names by which father is or has been known                         23. Date of birth 24. Social security number 25. Driver’s license number and state                   26. Mailing address and residence address (if different)       27. Eye color 28. Hair color 29. Height 30. Weight 31. Race 32. Scars, tattoos, etc.                                     33. Home telephone number 34. Work telephone number 35. Occupation                   36. Business/Employer’s name and address 37. Gross weekly income             38. Has husband applied for or does she receive public assistance? If yes, please specify kind. 39. AFCC and recipient identification numbers Yes No             40. a. Name of Minor Child Involved in Case b. Birth Date c. Age d. Soc. Sec. No. e. Residential Address                                                                                                                         41. a. Name of Other Minor Child of Either Party b. Birth Date c. Age d. Soc. Sec. No. e. Residential Address                                                             42. 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                                                                                                                         43. Names and addresses of person(s) other than the parties, if any, who may have custody of the child(ren) during the pendency of this case                    If any of the public assistance information changes before your judgment is entered, you are required to give the Friend of the Court written notice of the change. I declare that the statements above are true to the best of my information, knowledge and belief. Date Signature FOC 23 (5/93) VERIFIED STATEMENT MCR 3.206(B)