AG No. (for office use only): ________________________________________________
I. Custodial Parent (CP) - parent with child(ren) - information: PLEASE PRINT LEGIBLY
Full Name: ___________________________________________ Today’s date: __________________
Address: ___________________________________________ Home phone: __________________
___________________________________________ Cell phone: __________________
___________________________________________ Work phone: __________________
(If your mailing address is different than your home/physical address, please include that. You may use the back of this
questionnaire or attach additional sheets.)
Social Security number: _______________________________ Birth date: _____________________
Email address: ________________________________________________________________________
How did you hear about us? (i.e., FOC referral, TV, internet, etc): _________________________________
Child Support:
Amount of weekly/monthly support: _______________________ Case No.: _____________________
Case name: ___________________________________________ County: ______________________
Case worker’s name & phone number: _______________________________________________________
Arrearages owed: _______________________________ State portion (if any): __________________
Amount and date of last paid: __________________________ Copy of Order attached? ___ Yes ___ No
Date of Order for Support: _______________ Were birth expenses paid by Medicaid? ___Yes ___ No
Name(s) of child(ren) ______________________________________ Birth date: ______________
______________________________________ Birth date: ______________
______________________________________ Birth date: ______________
If more space is needed, you may use the back of this questionnaire or attach additional sheets.
Your (CP) relationship with the Non-Custodial Parent (NCP): check all that apply
___ Married ___ Divorced ___Never Married ___ Long-term ___ Short-term ___ Lived together
How long were you together? ______________________
Is there a history of Domestic Violence? ____ Yes ____ No
II. Non-Custodial Parent (NCP) – person paying child support – information:
Full Name: ______________________________________________ Birth date: ____________________
Social Security number: _________________________ Driver’s license number: _____________________
Address (last known): ________________________________________ Home phone: __________________
________________________________________ Cell phone: __________________
________________________________________ Work phone: __________________
Description of vehicle (if known): ____________________________________________________________
Physical Description of NCP - please attach a photograph if available. (NOTE: it will NOT be returned)
Race: _________ Height:__________ Weight: ________ Eye color: _______ Hair color: ________
Other identifying information (i.e., scars, marks, tattoos): ___________________________________________
NCP’s work/employment information:
Present/last known employer: ____________________________ Is the NCP self-employed? ____________
Address of employer: __________________________________ Phone number: ______________________
__________________________________ Supervisor’s name: ___________________
Dates of employment: _________________ Approximate income (wkly/monthly): ______________________
NCP’s immediate family information (including current spouse/significant other):
Name: ______________________________________ Relationship to NCP: ________________________
Address:______________________________________ Home phone: ______________________________
_______________________________________ Cell phone: _______________________________
Name: ______________________________________ Relationship to NCP: ________________________
Address:______________________________________ Home phone: ______________________________
_______________________________________ Cell phone: _______________________________
Name: ______________________________________ Relationship to NCP: ________________________
Address:______________________________________ Home phone: ______________________________
_______________________________________ Cell phone: _______________________________
III. Additional information:
1. Is the NCP the biological parent of each child?
2. Where did the NCP live when the court order was entered for child support?
3. What evidence is there the NCP had actual knowledge of the court order to pay? (i.e., personal service,
voluntary payments, appearances in court, etc.)
4. What is the NCP’s educational background? Include any specialized job training and or certifications.
5. State everything you know, to the best of your knowledge, (and the source of this information) about the
a) ability to work:
b) income:
c) assets:
6. Have/has the child(ren) lived with you continuously since the child support order was issued? If not,
please explain.
7. What contact does the NCP have with the child(ren)? What contact has occurred in the past?
8. Have you received any direct payments from the NCP or his/her family that did NOT go through Friend
of the Court?
9. Have you ever agreed to a support arrangement that is different from the court order? If so, please
10. Did you offer or agree not to request child support for any reason? If so, please explain.
11. Has the NCP ever been arrested for a crime? If so, please explain.
12. Are there any outstanding warrants for the NCP? If so, please explain.
13. What reasons might the NCP give for non-payment of child support?
14. Has the NCP ever declared bankruptcy? If so, please explain.
15. Do you have a copy of any tax returns filed during your marriage that you can attach? If not, please list
your income for the years your were married or lived together, if applicable.
16. Please describe the enforcement proceedings that have taken place and the agency that took action,
including the number of bench warrants issued (if any).
17. Has the NCP ever been investigated or prosecuted for criminal non-support? If so, please list which
agency (i.e., FOC, Attorney General’s Office, another state, etc.).
18. To your knowledge, has the NCP ever been disabled or received Social Security benefits for a disability?
19. State any other information you think would be helpful in the review of your case. You may attach
additional sheets if necessary.
20. Have/has the child(ren) ever been adopted by another party? If so, please explain.
21. Once a criminal charge has been brought, you cannot have it dropped or reduced. Any charge reduction
is in the discretion of the Prosecutor/Attorney General’s Office. As a result of prosecution, the NCP may
go to jail or prison and would not be paying child support while incarcerated. The proceedings may put a
strain on any relationship the NCP has with the child(ren) and/or possibly between you and your
child(ren). There is no assurance that you will receive any money due to criminal prosecution.
Importantly, you will be REQUIRED to testify in court by an issuance of a subpoena. With these things
in mind, by signing below you are requesting criminal prosecution of the NCP.
Signature: ___________________________________________________ Date: ___________________
Please mail completed questionnaire to:
Department of Attorney General
Child Support Division
PO Box 30758
Lansing, MI 48909-8258
Phone: 517-373-1111 Fax: 517-335-5328
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