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COMPLAINT FOR CUSTODY, PARENTINGTIME, AND CHILD SUPPORT DUE TOJUVENILE COURT PROCEEDINGSUSE THIS SET OF FORMS ONLY IF: You have a neglect or abuse case pending in the Wayne County Juvenile CourtYou still have at least one child on this case that is under 18 years oldPaternity has already been established either by the Court, a filed Affidavit of Parentage, or you are onthe child(ren)’s Birth CertificateYou want the Court to enter Orders for Custody, Parenting Time, and Child Support of the child(ren) inyour caseThis Com pl ai nt must be filed in the Coleman A. Young Municipal Center (CAYMC) building at TwoWoodward Avenue, Detroit, MI 48226 in Room 201. It will cost you 175.00 to file this Complaint (unlessfees are waived-see below). The County Clerk’s Office accepts cash; debit cards; MasterCard, AmericanExpress, and Discover credit cards; and certified checks or money orders made payable to the Wayne CountyClerk.If you cannot afford the filing fee, you can ask the Chief Judge for an Orderwaiving the filing fee. The Fee Waiver forms are included in this packet. Youcan ONLY do this in person and you must have a State-issued photo ID card andproof of your income and/or public assistance.If the Chief Judge waives your filing fee the waiver is only good the same day asit is signed. You must file your complaint that same day.The County Clerk’s office is open from 8:00 a.m. to 4:30 p.m.INSTRUCTIONS:1. Fill out all of the attached forms; thoroughly and completely. Failure to do so may result in your filing beingrejected or dismissed. Use BLACK OR BLUE INK ONLY2. Write your Domestic Division Case number (including the two letters at the end) in the upper right corner ofevery page and your Juvenile Court Case number (including the two letters at the end) underneath it.3. Attach a complete copy of your most recent Juvenile Court Order(s) to your forms.4. Leave the forms in numerical order. Make 3 sets of copies of pages 1 through 4 and all of yourattachments before you bring them to Court to file them.5. Bring all the original forms plus the 3 sets of copies to file.FD/FOC 4164 (03/19)

6. You will be instructed to complete a form (MC 21), which lists all of your prior cases involving this minorchild(ren). You must go to the Record Room located in the basement of CAYMC to confirm and list all priorcases.7. Always keep a copy of every paper you file with the Court and bring them to the hearing.IF YOU ARE FILING IN PERSON:1. Take your original set of complaint, your copies, Form MC 21(list of all prior cases), and your filingfees (or signed Order waiving filing fees) to the Wayne County Clerk in Room 201 (CAYMC 2nd floor). Youwill be given case labels (stickers).2. Put case labels (stickers) in the upper right corner of all original documents and only on pages 1 and 2 ofeach of your copies. Case labels are free and available in Room201.3. If you have an Order waiving your filing fees, give it the Clerk.4. The Clerk will keep the original forms and have you pay at the Cashier counter.IF YOU ARE FILING BY MAIL:1. Note: You cannot obtain a filing fee waiver by mail.2. Write your Case Number in the upper right corner of every page.3. Mail your original forms, 3 sets of copies and a money order or certified check for the filing fees to: WayneCounty Clerk, Room 201, Coleman A.Young MunicipalCenter,Detroit, MI 48226.4. Keep copies of everything you mail to the Court.5. Include a Self-Addressed Stamped Envelope and a letter asking the County Clerk to mail you a receipt anda copy of your motion stamped “filed.”6. You will receive your hearing date by mail.QUESTIONS?Call the Wayne County Friend of the Court at 877-543-2660 Employees of the Friend of the Court and theWayne County Circuit Court cannot give you legal advice or help preparing documents. General CourtInformation can be found on the website: www.3rdcc.org.Failure to complete all of the above steps may result in delay or dismissal of your motion.The Court is required by law to use the Michigan Child Support Formula to set the child supportamount, unless the Court finds that application of the formula would be unjust or inappropriate.MCR 2.002FD/FOC 4164 (03/19)

STATE OF MICHIGANTHIRD JUDICIAL CIRCUITWAYNE COUNTY2 Woodward Ave, Detroit, MI 48226COMPLAINT FOR CUSTODY, PARENTINGTIME, AND CHILD SUPPORT DUE TOJUVENILE COURT PROCEEDINGSPlaintiff’s name, address, telephone number and email:CASE NO.(DC)Defendant’s name, address, telephone number and email:vThere is an action currently pending involving the family or family members who are subject to a juvenile courtpetition in case no. and is assigned to Judge .1.Mother is a resident of County, State of .2.Mother has has not been a resident in Michigan for at least 6 months and has has not been a resident ofWayne County for at least 10 days immediately preceding the filing of this Complaint.3.Father is a resident of County, State of .4.Father has has not been a resident in Michigan for at least 6 months and has has notWayne County for at least 10 days immediately preceding the filing of this Complaint.5.The minor child(ren) has has not continuously been a resident in Michigan for at least 6 months and has has notbeen a resident of Wayne County for at least 10 days immediately preceding the filing of this Complaint.6.The parties are7.The Mother was was not married to another person at the time of the birth of the child(ren) and the child(ren) was was not born within 10 months of a Judgment of Divorce to another person.8.Mother and Father have a minor child(ren) together. The complete name and date of birth for each child is: are notbeen a resident ofmarried to one another.(Attach additional sheets if necessary)9.DOB:DOB:DOB:DOB:Mother and Father acknowledged paternity by signing an Affidavit of Parentage or are listed on the Birth Certificate for the followingminor child(ren):10. Attached is a copy of the Affidavit of Parentage or Birth Certificate for each minor child listed. A copy of the Affidavit ofParentage or Birth Certificate for each minor child must be attached to confirm that paternity has been established.11. Pursuant to MCL 722.1209, you must complete and attach Uniform Child Custody Jurisdiction Enforcement Act Affidavit or thiscomplaint will be dismissed.12. Physical Custody (party child primarily lives with): Mother Father Both parties is/are fit and proper to havephysical custody of the minor child(ren) of the parties and it is in the best interests of the minor child(ren) to award sole joint physical custody of the minor child(ren) to Mother Father Both parties.13. Legal Custody (important decisions involving child – medical; educational; religious): Mother Father Bothparties is/are fit and proper to make major decisions regarding the minor child(ren) of the parties and it is in the best interests ofthe minor child(ren) to award sole joint legal custody of the minor child(ren) to Mother Father Both parties.FD/FOC 4164 (03/19)Page 3 of 4

STATE OF MICHIGANTHIRD JUDICIAL CIRCUITWAYNE COUNTY2 Woodward Ave, Detroit, MI 48226COMPLAINT FOR CUSTODY, PARENTINGTIME, AND CHILD SUPPORT DUE TOJUVENILE COURT PROCEEDINGSPlaintiff’s name, address, telephone number and email:CASE NO.(DC)Defendant’s name, address, telephone number and email:v14. Parenting Time: Mother Fatherminor child(ren) to award reasonable is is not fit and proper for parenting time and it is in the best interests of the specific supervised reserved parenting time.15. The minor child(ren) need financial support, including health and hospitalization insurance, other medical support, and child-careexpenses. Child support and other expenses should be calculated and ordered according to the Michigan Child Support Formula.I REQUEST:16. The Court award Mother Father Both parties be given17. The Court award Mother Father Both parties be given18. Mother Fatheraward reasonable sole sole joint physical custody of the minor child(ren). joint legal custody of the minor child(ren). is is not fit and proper for parenting time and it is in the best interests of the minor child(ren) to specific supervised reserved parenting time.19. The Court enter an Order for Child Support, including medical and child-care expenses, as calculated according to the MichiganChild Support Formula.20. The parties be ordered to provide health and hospitalization insurance for the minor child(ren) and to pay medical, dental,orthodontic, and hospital expenses not covered by insurance, both permanently and while this action is pending.21. Any other relief that the court deems fair and proper.I declare that the statements above are true to the best of my information, knowledge, and belief.DatePlaintiffDatePlaintiff‘s AttorneyFD/FOC 4164 (03/19)Page 4 of 4

Approved, SCAOSTATE OF MICHIGANCIRCUIT COURT - FAMILY DIVISIONCOUNTYCASE NO.CASE INVENTORY ADDENDUM(FAMILY DIVISION)Plaintiff’s namePETITION NO.Defendant’s namevIn the matter ofInstructions: List any known pending or resolved family division cases involving the person(s) named in the complaint orpetition or family members of the person(s) named in the complaint or petition. Then, attach the completed form to the complaintor petition. Complete and attach additional sheets if necessary.Examples of family division cases include personal protection orders, divorce, custody, paternity, child support, juveniledelinquency, and child protective proceedings. See MCL 600.1021 for a complete list.Note: You must serve this form on the other parties with the summons and complaint or petition.Court information (name, number, and county/state)This courtOther court or tribunal:Case nameCase / File no.Assigned judgeCase statusPendingResolvedAre support or custody/parenting time orders in effect?SupportCustody/Parenting TimeCourt information (name, number, and county/state)This courtOther court or tribunal:Case nameCase / File no.Assigned judgeCase statusPendingResolvedAre support or custody/parenting time orders in effect?SupportCustody/Parenting TimeCourt information (name, number, and county/state)This courtOther court or tribunal:Case nameCase / File no.Assigned judgeCase statusPendingResolvedAre support or custody/parenting time orders in effect?SupportCustody/Parenting TimeCourt information (name, number, and county/state)This courtOther court or tribunal:Case nameCase / File no.Assigned judgeCase statusPendingResolvedAre support or custody/parenting time orders in effect?SupportCustody/Parenting TimeCourt information (name, number, and county/state)This courtOther court or tribunal:Case nameAssigned judgeDateMC 21Case / File no.Case statusPendingResolvedAre support or custody/parenting time orders in effect?SupportCustody/Parenting TimeSignature(8/18)CASE INVENTORY ADDENDUM (FAMILY DIVISION)MCR 3.206, MCR 3.931, MCR 3.961

Original - Court1st copy - FOC (if applicable)2nd copy - Defendant/Respondent3rd copy - Plaintiff/PetitionerApproved, SCAOSTATE OF MICHIGANJUDICIAL CIRCUITPROBATE COURTCOUNTYCASE NO.UNIFORM CHILD CUSTODY JURISDICTIONENFORCEMENT ACT AFFIDAVITCourt addressCourt telephone no.CASE NAME:1. The name and present address of each child (under 18) in this case is:2. The addresses where the child(ren) has/have lived within the last 5 years are:3. The name(s) and present address(es) of custodians with whom the child(ren) has/have lived within the last 5 years are:4. I do not know of, and have not participated (as a party, witness, or in any other capacity) in any other court decision, order, orproceeding (including divorce, separate maintenance, separation, neglect, abuse, dependency, guardianship, paternity,termination of parental rights, and protection from domestic violence) concerning the custody or parenting time of the child(ren),in this state or any other state, except: Specify case name and number, court name and address, and date of child custody determination, if one.5. I do not know of any pending proceeding that could affect the current child custody proceeding, including a proceeding forenforcement or a proceeding relating to domestic violence, a protective order, termination of parental rights, or adoption, in thisstate or any other state, except: Specify case name and number, court name and address, and nature of the proceeding.That proceedingis continuing.has been stayed by the court.Temporary action by this court is necessary to protect the child(ren) because the child(ren) has/have been subjected to orthreatened with mistreatment or abuse or is/are otherwise neglected or dependent. Attach explanation.6. I do not know of any person who is not already a party to this proceeding who has physical custody of, or who claims rights oflegal or physical custody of, or parenting time with, the child(ren), except: State name(s) and address(es) of each person.7. The child(ren)'s "home state" is.See back for definition of "home state."8. I state that a party's or child's health, safety, or liberty would be put at risk by the disclosure of this identifying information.I have filled this form out completely, and I acknowledge a continuing duty to advise this court of any proceeding in this state orany other state that could affect the current child-custody proceeding.Signature of affiantName of affiant (type or print)Subscribed and sworn to before me onMy commission expires:DateDateAddress of affiant,County, Michigan.Signature:Notary public, State of Michigan, County ofMC 416 (3/08)UNIFORM CHILD CUSTODY JURISDICTION ENFORCEMENT ACT AFFIDAVITMCL 722.1206, MCL 722.1209

"Home state" means the state in which the child(ren) lived with a parent or a person acting as a parent for at least 6 consecutivemonths immediately before the commencement of a child-custody proceeding. In the case of a child less than 6 months of age,the term means the state in which the child lived from birth with a parent or person acting as a parent. A period of temporaryabsence of a parent or person acting as a parent is included as part of the period.

Original - Friend of the court1st copy - Plaintiff/Attorney2nd copy - Defendant/AttorneyApproved, SCAOSTATE OF MICHIGANJUDICIAL CIRCUITCOUNTY1. Parent's last nameCASE NO.VERIFIED STATEMENTFirst name3. Date of birth2. Any other names by which parent is or has been knownMiddle name4. Social security number5. Driver's license number and state6. Mailing address and residence address (if different)7. E-mail address8. Eye color9. Hair color15. Home telephone no.10. Height11. Weight12. Race16. Work telephone no.13. Gender 14. Scars, tattoos, etc.17. Occupation18. Business/Employer's name and address19. Gross weekly income20. Did this parent apply for or receive public assistance? If yes, please specify kind and case number.YesNo21. Other parent's last nameFirst name23. Date of birthMiddle name22. Any other names by which parent is or has been known24. Social security number25. Driver's license number and state26. Mailing address and residence address (if different)27. E-mail address28. Eye color29. Hair color35. Home telephone no.30. Height31. Weight32. Race36. Work telephone no.33. Gender 34. Scars, tattoos, etc.37. Occupation38. Business/Employer's name and address39. Gross weekly income40. Did this parent apply for or receive public assistance? If yes, please specify kind and case number.YesNo41. a. Name and sex of minor child in caseM / F b. Birth date42. a. Name and sex of other minor child of either partyM / F b. Birth datec. Age d. Soc. sec. no.e. Residential addressc. Age d. Residential address43. Health care coverage available for each minor childa. Name of minor childb. Name of policy holderc. Name of insurance co./HMOd. Policy/Certificate/Contract/Group no.44. Name(s) and address(es) of person(s) other than parties, if any, who may have custody of child(ren) during pendency of this case.I declare that the statements above are true to the best of my information, knowledge, and belief.DateSignatureIf any of the public assistance information above changes before your judgment is entered, you are required to give the friend of the court written notice ofthe change. If you want child support services, complete form DHS 1201-D, available at your local friend of the court office or /domesticrelations/generalfoc/dhs1201d.pdfFOC 23 (3/16)VERIFIED STATEMENTMCR 3.206(B)

APPLICATION FOR IV-D CHILD SUPPORT SERVICES(For Privately Filed Domestic Relations Cases Only)FOR OFFICE USE ONLYApp RequestDateApp ReturnedDateIV-D CaseNumberState of MichiganFriend of the CourtInstructions: This is an application for IV-D child support services, and is intended only for parents filing a domestic relationscase (divorce, annulment, separate maintenance, paternity, or custody) on their own or through their own attorney. This form isnot intended for people without children or those who are not a party to a domestic relations case. This application is designedto be used with a Verified Statement, Judgment Information Form, or other similar court form.AUTHORITY: 45 Code of Federal Regulations 302.33. Completion of this application for IV-D child support services isvoluntary.Who does the child(ren) live with most of the time? (This information is usedfor administrative purposes only and has no impact on any pending custodyhearings.)Domestic Relations Filing/Docket Number (if available)What is your relationship to the child(ren) for whom you are applying for childsupport services?MotherMotherFatherBothFatherA. Mother’s InformationMother’s Name (First, Middle, Last)Mother’s Social Security NumberMother’s Mailing Address (Street, City, State, Zip Code)Mother’s Telephone NumberB. Father’s InformationFather’s Name (First, Middle, Last, Suffix)Father’s Social Security NumberFather’s Mailing Address (Street, City, State, Zip Code)Father’s Telephone NumberC. Family Violence DisclosureI believe that disclosure of my address or other identifying information may result in physical or emotional harm to me or thechild(ren). If yes, additional information will be requested by Friend of the Court staff.YesNoD. Acknowledgement for Child Support RecipientIf I am sent money in error or overpaid, the Michigan IV-D child support program will take action to correct this error. Bychecking the “yes” box below, I give the IV-D program permission to pay back the error or overpayment by keeping 25% (orotherwise as directed below) from my future child support payments. If I later change my mind, I must contact the Friend of theCourt office. Failure to check “yes” has no effect on my eligibility for IV-D child support services.Yes (Check one if different than 25%)10%50%No, please contact me before you try to recover an amount from my support payments.E. Acknowledgement for ApplicantI understand that I must provide my Social Security number pursuant to the Social Security Act, 42 USC 66(a)(13), in order forMichigan’s child support program to provide services.I have received or have had an opportunity to review a copy of DHS-Pub-748, Understanding Child Support: A Handbook forParents, at www.michigan.gov/childsupport in the Popular Forms section. I understand that I can also ask for a printed copyfrom the Friend of the Court.I request child support services available under Title IV-D of the Social Security Act for the child(ren) listed in my domesticrelations court filing (refer to DHS-Pub-748 for a list of available services).Applicant or Attorney of Record Signature (Signature is required)Applicant or Attorney of Record Printed NameDateIf signed by an attorney, (s)he is acting on behalf ofPrinted Name (Required)The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age,national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.Return this completed application to your local Friend of the Court Office.DHS-1201D (2-16)

Original - Court1st copy - Applicant2nd copy - Other partySTATE OF MICHIGANJUDICIAL DISTRICTJUDICIAL CIRCUITCOUNTY PROBATE3rd copy - Friend of the court(when applicable)JIS CODE: OSFCASE NO.FEE WAIVER REQUESTCourt addressCourt telephone no.Plaintiff’s/Petitioner’s namevPlaintiff’s/Petitioner’s attorney, and bar no.Defendant’s/Respondent’s nameDefendant’s/Respondent’s attorney and bar no.Probate In the matter ofInstructions: Complete the form and file it with the clerk. After you receive a decision on your request, youmust serve your request and the decision on the other party.I request a waiver of my filing fees for the following reason: (Check 1, 2, or 3)1. I receive the following type(s) of public assistance because of indigence:Food Assistance Program through the State of Michigan (also known as FAP or SNAP)Medicaid (including Healthy Michigan, CHIP, and ESO)Family Independence Program through the State of Michigan (also known as FIP or TANF)Women, Infants, and Children benefits (WIC)Supplemental Security Income through the federal government (SSI)Other means-tested public assistance:My public assistance case number(s) (if any) is.Write “none” if no case number. Do not write your SSN.2. I am represented by a legal services program or I receive assistance from a law school clinic becauseof indigence. The name of the legal services program or law school clinic is3. I am unable to pay the fees and I did not check item 1 or 2.My gross household income is everyThe number of people in my household is. Week/Two weeks/Month/YearMy source of income isList assets and their worth, such as bank accounts. If you need more space, attach a separate sheet.List obligations and how much you pay, such as rent or other debts. If you need more space, attach a separate sheet.I declare under the penalties of perjury that this request has been examined by me and that its contentsare true to the best of my information, knowledge, and belief.DateSignatureFOR CLERK USE ONLY: Payment of filing fees is waived.DateMC 20Signature of court clerk(2/19)FEE WAIVER REQUESTMCR 2.002

Fee Waiver Request(2/19)Case No.ORDERIT IS ORDERED:1. Payment of filing fees is waived because:a. Your gross household income is under 125% of the federal poverty guidelines.b. Your gross household income is above 125% of the federal poverty guidelines, but payment ofthe fees would constitute a financial hardship for you.c. Other:If you become able to pay the fees before this case is resolved, you must notify the court.2. The fee waiver request is denied because:a. Your gross household income is above 125% of the federal poverty guidelines and payment ofthe fees would not constitute a financial hardship for you.b. Other:DateJudgeBar no.

Defendant’s name, address, telephone number and email: 14. Parenting Time: Mother Father is is not fit and proper for parenting time and it is in the best interests of the minor child(ren) to award reasonable specific supervised reserved parenting time. 15. The minor child(ren) need financial support, including health and hospitalization insurance