State of Michigan department of HEALTH AND human services Lansing GRETCHEN WHITMER governor ELIZABETH HERTEL director
Request to Discharge State-Owed Debt
If you think you have good reasons for the Friend of the Court (FOC) to discharge (forgive or waive) your state-owed debt, please complete all information on this form, and return it to the FOC office where your court order is located. You may include more pages if you need more space. You may be asked to fill out more paperwork or provide proof of any of this information. FOC staff may schedule a follow-up meeting with you in person or by phone. If you have a court order in more than one county, please provide a copy of this form to each FOC office where you are seeking discharge of state-owed debt.
PERSONAL INFORMATION
Name	Date of birth	Social Security number	Driver’s license or state ID number
Address
Email	Home phone	Cell phone
Custodial party name(s) or docket number(s) (if known)
YOUR SITUATION
Below, please list who lives with you in your household, including children.
Name	Age	How is this person related to you?	Does this person have income/help pay household expenses?
Yes	No
Yes	No
Yes	No
Yes	No
Yes	No
Yes	No
Yes	No
1.	In your living situation, do you:	Rent	Own	Other
If other, explain:
2.	Do you have any child support cases in other states?	Yes	No
If yes, which state(s)?
Case number(s) if known:
3.	How much can you pay in current child support?	$	/month
4.	How much can you pay toward past-due support?	$	/month
5.	Would you be able to pay at least $1,000 at one time if the FOC “matched” the payment amount by discharging an equal amount of your state-owed debt?	Yes	No
If no, what amount could you pay all at one time to qualify for a matching discharge?	$
6.	Select your highest level of education:
Some high school	Two-year college degree (associate’s)
High school diploma/GED	Four-year college degree (bachelor’s)
Some college	Graduate degree (master’s, J.D., etc.)
7.	Do you have any specialized job training or licenses (examples: apprenticeship, certification, etc.)?
Yes	No
If yes, describe:
8.	Are you currently employed:	Full-time	Part-time	Unemployed
If unemployed, are you eligible for unemployment benefits?	Yes	No
If no, why not?
If unemployed at any time in the past three years, please identify below which months you were unemployed and not receiving unemployment benefits. (You weren’t eligible for benefits, or they had run out.) (Examples: 1/2011, 4/2012, etc.)
9.	Current employer name and address, if you have one:
Employer phone:
10.	Are you currently incarcerated (in jail or prison)?	Yes	No
If yes, complete the following:
Prisoner ID:
Date you expect to be released:
Prison/Jail location:
11.	Have you been incarcerated in the past?	Yes	No
If yes, list approximate start and end dates:
Start:	End:
Start:	End:
Start:	End:

12.	If you answered yes to Question 11, is it hard for you to find employment because of previous jail, prison, or probation sentences?	Yes	No
If yes, explain:
13.	Are you receiving Social Security payments?	Yes	No
If yes, provide a copy of your award letter or other proof to the FOC with this form, and complete the following:
Date you began receiving payments:
Type of payments:	SSI	Disability	Retirement
Are you permanently disabled according to the Social Security Administration (SSA)?	Yes	No
If yes, provide proof to the FOC with this form.
14.	Do you have a disability or other health issue(s) that may prevent you from working full-time, or from working at all?	Yes	No
If yes, provide proof to the FOC with this form.
15.	Do you currently receive public assistance (FIP, Medicaid, Food Stamps, etc.)?	Yes	No
If yes, what kind of assistance?
16.	Are you currently under a bankruptcy plan, or are you in the process of filing for bankruptcy?	Yes	No
17.	Do you expect to receive money from a will, estate, or trust?	Yes	No
18.	Are you currently living in a homeless shelter or taking part in a homelessness program?	Yes	No
If yes, length of time:
19.	In the past six months, have you been unable to pay medical bills (for either yourself or a family member) that you must pay?	Yes	No
20.	In the past six months, have you been unable to pay other bills that you must pay?	Yes	No
If yes, list bills you are unable to pay:
21.	Do you spend time with your child(ren) on a regular basis, attend school activities, and/or consistently exercise your court-ordered parenting time?	Yes	No
22.	In addition to your regular parenting time schedule, do you care for your children while the other parent is at work, at school, etc.?	Yes	No
If yes, list how many hours you do this per week:
23.	Do you provide non-money support (examples: transportation, clothing, etc.) to your children?	Yes	No
24.	Would you be willing to take a finance or budget class?	Yes	No
25.	Would you be willing to attend a jobs program?	Yes	No
26.	Would you be willing to do volunteer work?	Yes	No
If yes, how many hours per week are you willing to volunteer?

MONTHLY INCOME INFORMATION (List gross amounts – before taxes)
Income from job(s)	Workers’ compensation	Unemployment
Pension	Child support received (for all cases)	Spousal support
Social Security (SSI, disability, retirement, etc.)	Veterans Administration (VA) benefits
Settlement (legal settlement, insurance settlement, annuity)	Other income (describe source and monthly amount)
ASSET INFORMATION
Do you have a savings, checking, or other non-retirement account?	Yes	No
If yes, total amount in all accounts:	$	Date:
Bank or financial institution name:
Do you have retirement savings such as 401(k)?	Yes	No
If yes, total amount in all retirement accounts:	$	Date:
Bank or financial institution name:
Do you own or lease a car or truck?	Yes	No
If yes, number of cars/trucks owned or leased:
Do you have any of these items worth over $500?
Computer/Tablet:	Yes	No	Snowmobile:	Yes	No
Boat:	Yes	No	Jewelry:	Yes	No
Camper:	Yes	No	Tools:	Yes	No
Motorcycle:	Yes	No	Other:	Yes	No
AVERAGE MONTHLY EXPENSES (your share or the amount you pay)
Rent/mortgage	Electric	Cable/satellite TV	Water
$	$	$	$
Natural gas/oil	Child support	Phone (home/cell)	Credit cards
$	$	$	$
Medical bills	Car payments	Child care	Education
$	$	$	$
Spousal support	Insurance (car, life, medical, homeowners)
$	$
Other monthly payment(s) (describe)
$
DEBTS
Total balance on credit card(s)	Date	Total balance on medical bills (self)	Date
$	$
Total balance on medical bills (family)	Date
$
Do you owe restitution as a result of a crime?	If yes, amount owed
Yes	No	$
Do you owe fees, fines, and/or court costs?	If yes, amount owed
Yes	No	$
Do you owe someone as a result of a court judgment?	If yes, amount owed
Yes	No	$
Please note that if any of your state-owed debt is discharged based on incorrect, incomplete, or false information you provided, the FOC may reinstate the debt forgiven (add it back to the total amount owed in support). Please sign below to indicate that you believe the information you have provided on this form is correct and complete.
Signature	Print Name	Date
The Michigan Department of Health and Human Services will not exclude from participation in, deny benefits of, or discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, gender identification or expression, sexual orientation, partisan considerations, or a disability or genetic information that is unrelated to the person’s eligibility.