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STATE OF MICHIGAN CASE NO. and JUDGE JUDICIAL (County of Otsego)

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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 bimonthly monthly
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
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 monthly 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
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: $
Monthly payment: $
The monthly 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: $
Monthly 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
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 monthly benefit at retirement age. Use additional sheets if necessary.
Company or employer name:
Lump sum value: $
Estimated monthly 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, motorcycles, 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
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:
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
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
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), (D)
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
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STATE OF MICHIGAN CASE NO. and JUDGE JUDICIAL (County of Otsego)

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Completed 9 August 2020

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