Form FOC 39E Child-Care Verification - Michigan

Form FOC39E or the "Child-care Verification" is a form issued by the Michigan Circuit Court.

The form was last revised in March 1, 2014 and is available for digital filing. Download an up-to-date Form FOC39E in PDF-format down below or look it up on the Michigan Circuit Court Forms website.

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Original - Friend of the court
Approved, SCAO
Additional copies as needed
STATE OF MICHIGAN
CASE NO.
JUDICIAL CIRCUIT
CHILD-CARE VERIFICATION
COUNTY
Friend of the court address
Telephone no.
PARENT INFORMATION
Complete the top portion of this form and have your child-care provider complete the remainder.
It is your responsibility to return the completed form to the friend of the court.
Name
Name(s) and age(s) of child(ren) involved in this case
CHILD-CARE PROVIDER INFORMATION
Please attach a schedule of your most recent child-care rates.
The child-care provider must complete the remainder of this form for the child(ren) named above.
Name of provider
Address
City
State
Zip
County
Area code and
Telephone no.
Name and Age of Child
School Year Rates
Average No. of Hours/Week Hourly Rate
Total Weekly Rate
Name and Age of Child
Summer Season Rates
Average No. of Hours/Week Hourly Rate
Total Weekly Rate
Do you require payment for services even when children are absent to guarantee a position in your center?
Yes
No
If yes, please explain.
Does a federal or state agency or a public or private entity contribute all or a portion of the cost of child-care services?
Yes
No
If yes, please provide the agency name and amount contributed.
The information above is provided to enable the friend of the court to accurately report child-care costs in making a
child-support recommendation. I certify that the information provided above is true, accurate, and complete.
Date
Signature and title of provider
CHILD-CARE VERIFICATION
FOC 39e (3/14)
Original - Friend of the court
Approved, SCAO
Additional copies as needed
STATE OF MICHIGAN
CASE NO.
JUDICIAL CIRCUIT
CHILD-CARE VERIFICATION
COUNTY
Friend of the court address
Telephone no.
PARENT INFORMATION
Complete the top portion of this form and have your child-care provider complete the remainder.
It is your responsibility to return the completed form to the friend of the court.
Name
Name(s) and age(s) of child(ren) involved in this case
CHILD-CARE PROVIDER INFORMATION
Please attach a schedule of your most recent child-care rates.
The child-care provider must complete the remainder of this form for the child(ren) named above.
Name of provider
Address
City
State
Zip
County
Area code and
Telephone no.
Name and Age of Child
School Year Rates
Average No. of Hours/Week Hourly Rate
Total Weekly Rate
Name and Age of Child
Summer Season Rates
Average No. of Hours/Week Hourly Rate
Total Weekly Rate
Do you require payment for services even when children are absent to guarantee a position in your center?
Yes
No
If yes, please explain.
Does a federal or state agency or a public or private entity contribute all or a portion of the cost of child-care services?
Yes
No
If yes, please provide the agency name and amount contributed.
The information above is provided to enable the friend of the court to accurately report child-care costs in making a
child-support recommendation. I certify that the information provided above is true, accurate, and complete.
Date
Signature and title of provider
CHILD-CARE VERIFICATION
FOC 39e (3/14)
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