STATE OF MICHIGAN 6TH CIRCUIT COURT CASE NO. ADDENDUM TO PETITION PERSONAL PROTECTION ORDER (DOMESTIC � JUVENILE) Respondent v COUNTY OF OAKLAND PAGE Age/DOB OF (248) 975-9511 1200 N TELEGRAPH RD PONTIAC, MI 48341 Petitioner { } Moving party { } Check if non-public address filed with Court SOCIAL INFORMATION REGARDING JUVENILE RESPONDENT Father's name Mother's name Stepfather's name Guardian/Custodian's name Address Address Work phone Address Stepmother's name Home phone Home phone Home phone Work phone Work phone Work phone Work Phone Divorced: Date of Divorce Place of divorce: County State Custody to: { } Father { } Mother { } Other (state name and address): Child living with: { } Father { } Mother { } Stepfather { } Other: I need a personal protection order because respondent: { { { { { { { } } } } } } } Entered onto my property. Assaulted, attacked, beat, molested, or wounded me on or about the following dates: Threatened to kill or physically injure me on or about the following dates: Removed minor child(ren) from the individual having physical custody of the child(ren) without a court order. Interfered with me at my job or is threatening my job relationship or environment. Interfered with my efforts to remove my child(ren) or personal property from defendant's property. Did the following things which make me fear violence or interfere with my freedom: 1. When Where What 2 When Where What 3 When Where What (Attach extra sheets if necessary) VERIFICATION UNDER MCR 2.114(2)(b): I declare that the statements above are true to the best of my information, knowledge and belief. Date Signature of Petitioner CC-PPO 13 (06/00) Addendum to Petition for PPO Against a Minor (Domestic) American LegalNet, Inc. www.FormsWorkFlow.com 1 of 1