Personal Protection Order (PPO) Petition Instructions Please fill out the entire form following these instructions. Every section is numbered. You are the Petitioner! Step 1—Mark the Domestic or Stalking box describing the situation that pertains to your relationship (The Petitioner) with other person (The Respondent). Step 2—You are the Petitioner. Fill in your name and full address. (If you are in hiding, do not put your address on the form.) Step 3—The person you are filing against is the Respondent. Fill in the entire box including Respondent’s name, full address and description. Step 4—Mark all the boxes that apply to your relationship with the Respondent. Step 5—Indicate any other Court orders, judgments or pending cases between you and the Respondent. Please attach copies of these documents if issued in a County other than Kent or a State other than Michigan. (Police Reports are acceptable.) Step 6—Indicate acts already committed against you. ♦ For Domestic cases, mark all situations that apply for A through O. ♦ For Stalking cases, mark all situations that apply for E through O. Step 7—Do Not Sign Step 8—Do Not Sign American LegalNet, Inc. www.FormsWorkflow.com For Court Use Only STATE OF MICHIGAN Judge Kent County-17th Judicial Circuit/FAMILY DIVISION 180 Ottawa Avenue NW – Suite 3500 Grand Rapids MI 49503 616-632-5067 Petition for Personal Protection Order Step 1—Type of PPO Case Domestic Relationship (See #4 for definition.) Stalking - The petitioner and respondent are not husband and wife, have not resided in the same household together, Case Number: have no children in common, and have had no intimate dating relationship with one another. (No relationship whatsoever.) Step 2—Petitioner What is your age? Name: ___________________________________________________ Address: _________________________________________________ City, State, ZIP: ____________________________________________ Phone #: (______)__________________________________________ Step 4—The petitioner and respondent (mark all that apply): Were husband & wife, now divorced. Are husband & wife. Years married: ______ Have a child(ren) in common. # of children: ______ Reside or resided in the same household. From ______ to ______ Step 3—Respondent Name: ___________________________________________________ Address: _________________________________________________ City, State, ZIP: ____________________________________________ Phone #: (______)__________________________________________ Respondent’s Height: _______ Weight: _______ Race: ____________ Birthdate: __________ Hair color: __________ Eye color: __________ Parent’s Name if resp. is under 18: ____________________________ Is the respondent employed by any law enforcement agency that requires firearm possession? NO YES If yes, answer: Name of Supervisor: ________________________________________ Have or have had an intimate dating relationship. Address: _________________________________________________ Other, please describe: __________________________________ Phone #: (______)__________________________________________ Step 5—Do you have a case in another county or state with this person? Have you filed any police reports within the last three months? NO YES NO YES I need a personal protection order because of events occurred or threatened. Please see attached affidavit. Step 6—I ask the court to grant a personal protection order prohibiting the respondent from: STALKING SECTION ONLY (May not mark A—D): Entering onto the property wherever I live. I own rent my current E-Interfering with the petitioner’s efforts to remove his/her child(ren) or residence. Other: _____________________________________________ personal property from the premises solely owned or leased by the other The respondent(s’): party. (Are your personal possessions being held hostage from you at other residence?) Lives at the residence owned or leased in the petitioner’s name. F-Following petitioner. Address is not the petitioner’s address. G-Attempting to locate petitioner’s address and/or phone number. Has been jailed on domestic violence allegations and is restricted H-Approaching or confronting petitioner in a public place or on private under a no-contact order. property. (May be in same public place, just may not harass.) DOMESTIC SECTION ONLY: I-Entering onto or remaining on property owned, leased or occupied by A-Entering onto the property located at: (Day Care, schools, vacation property, etc.) petitioner. (Provides protection when at friends, neighbors, relatives, etc.) _____________________________________________________________ J-Sending mail, fax, email, pager, voice mail, answering machine, etc. B-Assaulting, attacking, beating, molesting or wounding: (Names) Other ______________________________________________________ _____________________________________________________________ K-Contacting Petitioner by phone. (Child(ren) issues, child(ren) speak w/ respondent.) C-Removing minor child(ren) from the petitioner who has court-ordered L-Placing an object or delivering an object to property owned, leased, or custody, except as allowed by a custody or parenting time order as long as occupied by petitioner. (Notes on vehicles, etc.) removal of the child(ren) does not violate other conditions of personal proM-Threatening to kill or physically injure: (Names) ___________________________ tection order. (Not intended to keep a parent away from their child. We cannot change visitation issues with a PPO). D-Having access to information in records concerning minor child(ren) of petitioner and respondent that will reveal petitioner’s address, telephone number, or employment address or that will reveal the child(ren)’s address or telephone number. (Only if you have child(ren) w/ respondent and are in hiding; interfering with finances, Dr. appts, etc.) Also may include E through O. _______________________________________________________________________________ N-Interfering with the petitioner at his/her place of employment or engaging in conduct that impairs his/her employment or environment. (School, volunteer work, etc.) O-Other: Engaging others to further harm/harass/intimidate petitioner/ ___________________________________________________________ I ask the Court to grant an ex-parte order because immediate and irreparable injury, loss, or damage will occur between now and a hearing or because notice will cause irreparable injury, loss or damage before the order can be entered. Step 7—I declare the above statements are true to the best of my information, knowledge and belief: ________________________________________________________________________________ Petitioner’s Signature Date Step 8— Next Friend Signature Interpreter Signature American LegalNet, Inc. www.FormsWorkflow.com ______________________________________________________________________________________________ Signature, Phone # w/ Area Code Date Personal Protection Order (PPO) Affidavit Instructions Hand Print or Type Only • Please read these instructions carefully. • Limit Affidavit to 240 words or less. • The Respondent will receive a copy of this affidavit so carefully word this document. • Please start on the front side of the affidavit. • The Judge will need to know how you know this person. • Tell what has happened in the past and what’s happening now. The Judge will require the dates on which the violence occurred. Stay current; don’t go back years. • The affidavit is all you have to convince the Judge of why the Court should be involved in your situation. • If you don’t provide enough facts then your PPO request could be denied. (Statutory requirements must be met in order to issue a PPO.) • The PPO Interviewer’s Office cannot translate nor write your statement. • Please do your best—per Michigan Court Rule, your hand-printing must be legible. • Do Not Sign American LegalNet, Inc. www.FormsWorkflow.com Personal Protection Order (PPO) Affidavit For Office Use Only Judge: 1st Petition 1st 2nd 3rd 4th Amended Extension Permanent Case #: ____________________________ Start Story Here: (REMEMBER—Affidavits over 240 words may be returned.) • Continue Story on next page. • Does Respondent own firearms? Yes No Don’t Know • Has Respondent threatened to harm/kill you with a gun? Yes No • Does Respondent’s employment require firearm possession? Yes Has Access No ______________________________________________________________________ Affiant Signature Date Print Name I have written this statement for the Petitioner at the Petitioner’s direction because Petitioner cannot: Read Write Speaks another language ________________________________ ___________________________________________(Sworn In) _____________________________________ Signature of Interpreter Print Name ___________________________________________________________ Phone Number w/ Area Code ____________________________________________________________________ (Sworn Signature of Next Friend (If the Petitioner is a minor) In) _________________________________________ Print Name Subscribed and sworn to before me on ____________________________, in the County of Kent, Michigan. My commission expires ___________________________. __________________________________________________ Notary Public Signature American LegalNet, Inc. www.FormsWorkflow.com Personal Protection Order (PPO) Affidavit Page 2 Please limit your statement to pages one and two. American LegalNet, Inc. www.FormsWorkflow.com