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STATE OF MICHIGAN JUDICIAL CIRCUIT DOMESTIC RELATIONS VERIFIED FINANCIAL INFORMATION FORM CASE NO. and JUDGE Approved, SCAO Form CC 320, Rev. 1/20-Ver. 2 MCR 3.206 Page 1 of Plaintiff’s name v Defendant’s name TO BOTH THE PLAINTIFF AND THE DEFENDANT: • You must complete this form and serve it on the other party within 28 days after the date of service of defendant’s initial responsive pleading to the complaint that started the case. • Completing this form is not necessary if you and the other party agreed in writing not to exchange the form, or if a settlement agreement, consent judgment, or other final order that resolves the case has been signed by you and the other party at the time the case is filed. • A proof of service must be filed with the court after you have served this form on the other party. • Do not file this document with the court. Note: If you are a victim of domestic violence, sexual assault, or stalking by another party in this case, you may leave out any information which might lead to the location of where you live or work, or where a minor child (if any) may be found. If you are self-represented and do not provide your address because of domestic violence, you will need to give this form to the other party at the first scheduled matter, or as otherwise directed by the court or agreed to by the parties. If you leave out information, you must explain the reasons why in a sworn affidavit and file it with the court by the date this disclosure form is due to the other party. Name: First, middle, and last name Phone: Address: Street City State Zip Date of birth: Social Security Number: Driver’s license number and state: Provide information for each source of employment income. Use additional sheets if necessary. Employer name: Self-employed Employer address: Street City State Zip Occupation: Professional license, type and no.: Gross income (before taxes and other deductions): $ weekly biweekly Hourly pay rate (including shift premium and cost of living adjustment): $ Total regular hours worked per pay period: Average overtime hours for past 12 months: If self-employed, list each owner’s draw you have made during the past twelve months: PERSONAL INFORMATION EMPLOYMENT INFORMATION 46th ---PAGE BREAK--- Domestic Relations Verified Financial Information Form (1/20-Ver. 2) Page 2 of Case No. Employment benefits: health insurance vision insurance dental insurance life insurance retirement car allowance Amount expense reimbursements other If unemployed and not receiving unemployment or worker’s compensation benefits, or working part-time only, provide the following information regarding your last full-time employer: Never employed full-time. Name of last full-time employer: Name Position: Address of last full-time employer: Street City State Zip Last day employed full-time: Date Length of time employed: Reason for leaving last full-time employment: Gross earnings per pay period (earnings before taxes): $ Provide income from all other sources. Commissions Unemp. Benefits Nat’l Guard/Res. Drill Bonuses Strike Pay Armed Services Profit Sharing SUB Pay Allowance for Rent Interest Sick Benefits Rental Income Dividends Workers’ Comp. Spousal Support Annuities Soc. Sec. Benefits State Disability Asst. Pensions/Longevity VA Benefits F I P Deferred Comp/IRA Disability Ins. SSI Trust Funds GI Benefits Other Does anyone pay any living or housing expenses on your behalf? yes no If yes, provide details of the payments including amount per month paid on your behalf: NOTE: Attach your four most recent paycheck stubs, or a statement from your employer(s) of wages and deductions, and year-to-date earnings, and a copy of your last federal and state income tax returns, including all schedules to this form. If self-employed, also attach a copy of your three most recent business tax returns and/or corporate returns. OTHER INCOME ---PAGE BREAK--- Domestic Relations Verified Financial Information Form (1/20-Ver. 2) Page 3 of Case No. Provide asset information for divorce, separate maintenance, and annulment cases only (DO and DM case types). Real Property Provide the following information for any real estate in which you own an interest. Use additional sheets if necessary. Address of property: Street City State Zip Date of purchase: Date Estimated value: $ SEV: $ Balance on mortgage/land contract: $ payment: $ The payment includes: taxes. insurance. Name of lender: Property is titled as follows: Name(s) and specific ownership interest in property Primary residence Other: Balance of equity loan or line of credit: $ payment: $ Name of lender for equity loan or line of credit: Financial Accounts List all financial accounts including, but not limited to, bank, credit union, CDs, stocks, annuities, IRAs, 401(k), 403(b), trust, Michigan Education Savings Program (MESP), and health savings accounts in which you have an interest. Use additional sheets if necessary. Type of account Current balance (before taxes) Balance 90 days before current balance Account no. $ $ Name of institution as of: Name on account Type of account Current balance (before taxes) Balance 90 days before current balance Account no. $ $ Name of institution as of: Name on account Type of account Current balance (before taxes) Balance 90 days before current balance Account no. $ $ Name of institution as of: Name on account Type of account Current balance (before taxes) Balance 90 days before current balance Account no. $ $ Name of institution as of: Name on account ASSET INFORMATION ---PAGE BREAK--- Domestic Relations Verified Financial Information Form (1/20-Ver. 2) Page 4 of Case No. Pension List all defined benefit plans that will pay you a benefit at retirement age. Use additional sheets if necessary. Company or employer name: Lump sum value: $ Estimated payment: $ Earliest date you are eligible to receive your pension benefit: Date Life Insurance Provide the following information for all life insurance policies in which you have an interest. Use additional sheets if necessary. Insurance Company: Policy no.: Policy owner: Beneficiary: Death benefit: $ Premium: $ per week/month/year Cash/surrender value: $ as of Date . Taxable Employer provided: yes no Motorized Vehicles List all motorized vehicles in which you own an interest. Include automobiles, boats, snowmobiles, recreational vehicles, etc. Include information on any loans that you co-signed for the benefit of another person. Use additional sheets if necessary. Year, make and model Amount owed Title holder $ Lender as of Estimated value Year, make and model Amount owed Title holder $ Lender as of Estimated value Year, make and model Amount owed Title holder $ Lender as of Estimated value Year, make and model Amount owed Title holder $ Lender as of Estimated value ---PAGE BREAK--- Domestic Relations Verified Financial Information Form (1/20-Ver. 2) Page 5 of Case No. Personal Property List all other items of personal property such as furniture, jewelry, gold, silver, collectibles, artwork, guns, furs, tools, etc. Do not include items of minimal value such as clothing. Use additional sheets if necessary. Description of property Estimated value Date purchased or acquired $ $ $ $ $ $ $ $ $ $ Total: $ Miscellaneous Use additional sheets if necessary. 1. Do you own or have access to any safe deposit boxes? yes no If yes, provide information on where it is located and a list of the contents: 2. Are any accounts, money, or assets being held for your benefit? yes no If yes, provide amount, where it is held, and the reason it is being held: 3. Are you holding or acting as the custodian of any money, accounts, or asset for the benefit of someone else? yes no If yes, describe what it is, where it is located, and why you are holding it or acting as custodian: 4. Do you have any ownership interests in any type of business? yes no If yes, describe the business and what your ownership interests are: 5. Are there any other assets or income to which you are entitled, or to which you believe you will become entitled? yes no If yes, describe the assets, their value, and why you believe you are or will be entitled to them: ---PAGE BREAK--- Domestic Relations Verified Financial Information Form (1/20-Ver. 2) Page 6 of Case No. 6. Are there any debts that are owed to you? yes no If yes, describe who owes the money, how much is owed, the amount and frequency of payments, the purpose of the loan, and the loan end date: 7. Are there any other items you own that have financial value such as electronic assets, season tickets, or electronic currency such as bitcoin? yes no If yes, describe asset, where it is held and its current value as of a specific date: 8. Are there any outstanding court cases other than this one involving you, your spouse, or family members that may result in an award for or against you? yes no If yes, describe the case, where it is filed and the possible award or liability: Provide debt information for divorce, separate maintenance, and annulment cases only (DO and DM case types). Credit cards, personal loans, student financial aid loans, other unsecured loans Include all loans that are for your benefit or that you are a co-signer on for another person. Use additional sheets if necessary. Type of debt Balance owed Name of lender $ Account no. as of Name(s) on account Type of debt Balance owed Name of lender $ Account no. as of Name(s) on account Type of debt Balance owed Name of lender $ Account no. as of Name(s) on account Type of debt Balance owed Name of lender $ Account no. as of Name(s) on account Attach the last three statements for all accounts. DEBTS ---PAGE BREAK--- Domestic Relations Verified Financial Information Form (1/20-Ver. 2) Page 7 of Case No. Court ordered financial obligations Provide the following information for all your court-ordered financial obligations including, but not limited to, child or spousal support in a different case, garnishment, civil judgment against you, and court-ordered fines, fees or restitution. Use additional sheets if necessary. Type of obligation: Child support, spousal support, garnishment, judgment, etc. Payment amount: $ per Balance (if applicable): $ Estimated end date (if applicable): Date Court: Case no.: Provide miscellaneous information for divorce, separate maintenance, and annulment cases only (DO and DM case types). 1. Have you ever filed for bankruptcy? yes no If yes, provide the date, case number, and current status of the bankruptcy: 2. Do you claim that any of the assets or debts that you listed are your separate property? yes no If yes, provide detailed information on which asset(s) or debt(s) and why you think they are your separate property: 3. If there is any additional information regarding assets, debts, business interests, stocks, bonds, anticipated income, or any financially related information of any kind that has not been disclosed on this form, provide that information below. I declare that the statements above are true to the best of my information, knowledge, and belief. Date Signature Subscribed and sworn to before me on Date . Deputy clerk/Notary public signature My commission expires on . Name (type or print) Notary public, State of Michigan, County of . Acting in the County of . This notarial act was performed using an electronic notarization system or a remote electronic notarization platform. MISCELLANEOUS ---PAGE BREAK--- On the date below I sent by first-class mail a copy of to: List names and addresses. I declare that the statements above are true to the best of my information, knowledge, and belief. Date Signature Name (type or print) Court telephone no. MCR 2.107(C)(3), Court address CASE NO. STATE OF MICHIGAN JUDICIAL DISTRICT JUDICIAL CIRCUIT COUNTY PROBATE PROOF OF SERVICE VERIFIED FINANCIAL INFORMATION FORM v Defendant(s) Plaintiff(s) Probate In the matter of Juvenile In the matter of 46th 225 W Main St. Gaylord, MI 49735 (989)731-7500 Domestic Relations Verified Financial Information Form