Employment Status Disclosure {FOC 22b}

Approved, SCAO STATE OF MICHIGAN CASE NO. JUDICIAL CIRCUIT EMPLOYMENT STATUS DISCLOSURE COUNTY Friend of the Court address FAX number Telephone no.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 Title Telephone no. Date 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, pleasenote it is a court order authorized under MCL 552.601 et seq. and your compliance is required. 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 which apply. The individual was never employed here. The individual quit was fired was terminated was laid off on Date The individual is receiving unemployment from: Name Address ( ) City, state, zip Telephone no. The individual is receiving benefits from: Name Workers compensation Disability Address ( ) City, state, zip Telephone no. The individual may now be working at: Name Address ( ) City, state, zip Telephone no. The last known address of the individual is: Address ( ) City, state, zip Telephone no.Date Name of person preparing form (type or print) Signature of person preparing form ( ) Telephone no. FOC 22b (6/03) EMPLOYMENT STATUS DISCLOSURE