Approved, SCAO STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY A PERSONAL PROTECTION ORDER AGAINST A MINOR (DOMESTIC RELATIONSHIP), PAGE 1 EX PARTE Court address ORI MIPetitioner's name Respondent's name, address, and telephone no. v Address and telephone no. where court can reach petitioner Full name of respondent (type or print) * Height Weight CASE NO. B Court telephone no. C D 3rd copy - Petitioner (pink) 4th copy - Return (yellow) 5th copy - Return (goldenrod) Original - Court 1st copy - Law enforcement agency (file) (green) 2nd copy - Respondent (blue) Race * Driver's license number (if known) Sex * Date of birth or Age* Hair color Eye color Other identifying information *These items must be filled in for the police/sheriff to enter on LEIN; the other items are not required but are helpful. **Needed for NCIC entry. Full name of respondent's parent, guardian, custodian (type or print) Full name of respondent's parent, guardian, custodian (type or print) Address and telephone no. if different from above E Address and telephone no. if different from above **needed for NCIC entry Date: Judge: Bar no. 1. This order is entered without a hearing. **after hearing. THE COURT FINDS: 2. A petition requested respondent be prohibited from entry onto the premises, and either the petitioner has property interest in the premises, or respondent does not have a property interest in the premises. 3. The respondent is less than 18 years of age, is unemancipated, and is not the minor child of the petitioner. 4. The petitioner is less than 18 years of age, is unemancipated, and is not the minor child of the respondent. 5. The petitioner requested an ex parte order which should be entered without notice because irreparable injury, loss, or damage will result from delay required to give notice or notice itself will precipitate adverse action before an order can be issued. 6. The respondent poses a credible threat to the physical safety of the petitioner and/or a child of the petitioner. 7. The respondent **is the spouse or former spouse of the petitioner, had a child in common with the petitioner, or is residing or had resided in the same household as the petitioner. has or had a dating relationship with the petitioner. ** IT IS ORDERED: 8. is prohibited from: Name a. entering onto property where petitioner lives. b. entering onto property at ** . c. assaulting, attacking, beating, molesting, or wounding . Name d. removing minor children from petitioner who has legal custody, except as allowed by custody or parenting time order provided removal of the children does not violate other conditions of this order. An existing custody order is dated . An existing parenting time order is dated (PLEASE SEE OTHER SIDE) CC 376M (2/08) . MCL 600.2950, MCL 712A.2h, MCR 3.705, MCR 3.706, 18 USC 922(g)(8)(c) PERSONAL PROTECTION ORDER AGAINST A MINOR (Domestic Relationship), Page 1 American LegalNet, Inc. www.FormsWorkflow.com Approved, SCAO STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY A PERSONAL PROTECTION ORDER AGAINST A MINOR (DOMESTIC RELATIONSHIP), PAGE 2 EX PARTE Court address ORI MIPetitioner's name B CASE NO. Court telephone no. v Respondent's name IT IS FURTHER ORDERED: 8. (continued from page 1) e. stalking as defined under MCL 750.411h and MCL 750.411i which includes but is not limited to: ** following or appearing within sight of the petitioner. appearing at workplace/residence of the petitioner. approaching or confronting the petitioner in a public place or on private property. entering onto or remaining on property owned, leased, or occupied by the petitioner. sending mail/other communications to the petitioner. contacting the petitioner by telephone. placing an object on or delivering an object to property owned, leased, or occupied by the petitioner. f. interfering with petitioner's efforts to remove his/her children or personal property from premises solely owned or leased by respondent. ** g. threatening to kill or physically injure . Name h. interfering with petitioner at his/her place of employment or education or engaging in conduct that impairs his/her employment or educational relationship or environment. i. having access to information in records concerning a minor child of petitioner and respondent that will reveal petitioner's address, telephone number, or employment address or that will reveal the child's address or telephone number. ** j. purchasing or possessing a firearm. k. other: 9. As a result of this order, federal and/or state law may prohibit you from possessing or purchasing ammunition or a firearm (including a rifle, pistol, or revolver). 10. a. If the respondent is 17 years of age or more, violation of this order subjects the respondent to immediate arrest and to the civil and criminal contempt powers of the court. If found guilty of a violation, the respondent shall be imprisoned for not more than 93 days and may be fined not more than $500.00. b. If the respondent is less than 17 years of age, violation of this order subjects the respondent to immediate apprehension or being taken into custody. If found guilty of a violation, the respondent shall be subject to the dispositional alternatives listed in MCL 712A.18. 11. This order is effective when signed, enforceable immediately, and remains in effect until . This order is enforceable anywhere in this state by any law enforcement agency when signed by a judge, and upon service, may also be enforced by another state, an Indian tribe, or a territory of the United States. If respondent violates this order in a jurisdiction other than this state, respondent is subject to enforcement and penalties of the state, Indian tribe, or United States territory under whose jurisdiction the violation occurred. 12. The court clerk shall file this order with , Name of law enforcement agency who will enter it into the LEIN. 13. The respondent may file a motion to modify or terminate this order. If this is an ex parte order, a motion to modify or terminate this order and a request for a hearing must be made within 14 days after the respondent has been served or has received actual notice of this order. Forms and instructions are available from the clerk of the court. 14. A motion to extend the order must be filed 3 days before the expiration date in item 11 or else a new petition must be filed. 15. Other: Date and time issued CC 376M (2/08) Judge PERSONAL PROTECTION ORDER AGAINST A MINOR (Domestic Relationship), Page 2 American LegalNet, Inc. www.FormsWorkflow.com PROOF OF SERVICE Personal Protection Order Against a Minor Case No. TO PROCESS SERVER: You must serve the personal protection order against a minor and file proof of service with the court clerk. If you are unable to complete service, you must return this original and all copies to the court clerk. CERTIFICATE / AFFIDAVIT OF SERVICE / NONSERVICE OR OFFICER CERTIFICATE I certify that I am a sheriff, deputy sheriff, bailiff, appointed court officer, or attorney for a party [MCR 2.104(A)(2)], and that: (notary not required) AFFIDAVIT OF PROCESS SERVER Being first duly sworn, I state that I am a legally competent adult who is not a party or an officer of a corporate party, and that: (notary required) I served a copy of the personal protection order against a minor by: personal service registered mail, delivery restricted to the respondent and the parent(s), guardian(s), or custodian(s) of the respondent (return receipt attached) on: Name of respondent Complete address of service Day, date, time Name of parent/guardian/custodian Complete address of service Day, date, time Name of parent/guardian/custodian Complete address of service Day, date, time Law enforcement agency Complete address of service Day, date, time I have personally attempted to serve a copy of the personal protection order against a minor on the following respondent and have been unable to complete service. Respondent's name Complete address of service I declare that the statements above are true to the best of my information, knowledge, and belief. Name (type or print) Service fee Miles traveled $ Mileage fee $ Total fee Signature $ Title Subscribed and sworn to before me on My commission expires: , Date Signature: Date County, Michigan. Deputy court clerk/Notary public Notary public, State of Michigan, County of ACKNOWLEDGMENT OF SERVICE I acknowledge that I have received a copy of the personal protection order against a minor on . Day, date, time Signature of respondent Signature of respondent's parent/guardian/custodian Signature of respondent's parent/guardian/custodian MCR 2.105(A) American LegalNet, Inc. www.FormsWorkflow.com