Friend of the Court
Please submit your Friend of the Court Inquiry on this form. Your case information will be
updated and the Friend of the Court Staff will respond to your inquiry by email.
CASE/DOCKET NO.
YOUR SOCIAL SECURITY NUMBER
TODAY’S DATE
YOUR LAST NAME YOUR FIRST NAME
MIDDLE INITIAL
YOUR CURRENT HOME ADDRESS
CITY
STATE
ZIP CODE
YOUR DAYTIME PHONE EVENING OR OTHER PHONE DRIVER’S LIC. OR STATE I.D. #
ALTERNATE ADDRESS CITY STATE/ZIP CODE
LTERNATE PHONE
YOUR EMPLOYER OR SOURCE OF INCOME EMPLOYER’S ADDRESS EMPLOYER PHONE #
Is this a new employer?
yes no
MEDICAL INS. PROVIDER & POLICY # Is the dependent
covered?
yes no
LAST NAME OF OTHER PARTY ON THIS CASE FIRST NAME
OTHER PARTY’S HOME ADDRESS CITY STATE ZIP CODE
OTHER PARTY’S SOCIAL SECURITY NUMBER OTHER PARTY’S EMPLOYER OR SOURCE OF INCOME
OTHER PARTY’S EMPLOYER ADDRESS
OTHER’S PARTY’S
EMPLOYER PHONE
Is this a new employer? yes no
WHAT IS YOUR REQUEST TODAY?
By submitting this form, I certify that I am a party to this case, the information provided above is
true and correct, and I am applying for/requesting Title IV-D services.
__________________________________________________________________________________________________
The Wayne County Friend of the Court uses phone technology to contact parties regarding child support payments.
