Request to Protect Information - Michigan Department of ...
| |
|REQUEST TO PROTECT INFORMATION |
|Michigan Department of Health and Human Services |
| |
|Name (print first, middle, last) |Date of Birth |
| | |
|Address Line 1 (where I live) |Address Line 2 |
| | |
|City |State |Zip Code |
| | | |
|Docket Number |IV-D Case Number |
| | |
| |
|I fear for the safety of myself and/or my child(ren) due to past or possible future domestic violence or child abuse. I ask the child support program not to share the |
|following information with other people on my case(s): |
| |
|Social Security number |
|Address(es) |
|Phone number(s) |
|Driver’s license number |
| |
|I ask the child support program to send my mail to the alternate address below: |
| |
|Address Line 1 |Address Line 2 |
| | |
|City |State |Zip Code |
| | | |
| |
|By signing this document, I promise all information on this form is true and correct. |
| |
|Signature |Date |
| | |
| |
|After completing this form, you may: |
| |
|Fax it to the Office of Child Support Central Operations at 517-335-3030; or |
|Deliver it to the local Prosecuting Attorney office or Friend of the Court office that is working on your case. |
| |
|**This document contains confidential information, meant for a specific individual and purpose, and is protected by law. If you are not the intended recipient, you must |
|destroy this document.** |
| |
|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. |
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- pdreport us
- emergency vehicle operation
- micigan department of corrections
- hiring procedure for substitute bus drivers
- request to protect information michigan department of
- latest updates Últimas novedades michigan immigrant
- new driver orientation toolboxtopics
- initial foster adoption home evaluation michigan
- foreword university of michigan
Related searches
- state of michigan department of education
- michigan department of treasury
- michigan department of treasury online re
- michigan department of treasury taxes
- michigan department of treasury forms
- michigan department of treasury website
- michigan department of treasury address
- michigan department of revenue website
- michigan department of revenue forms
- michigan department of revenue contact
- michigan department of education jobs
- michigan department of revenue