Original – Court 1st copy – Judge/Assignment clerk (green) 2nd copy – Respondent (blue) Approved, SCAO STATE OF MICHIGAN 6th JUDICIAL CIRCUIT OAKLAND COUNTY PETITION FOR PERSONAL PROTECTION ORDER (DOMESTIC RELATIONSHIP), PAGE 1 3rd copy – Petitioner (pink) 4th copy – Return (yellow) CASE NO. Court address 1200 N. Telegraph Road, Pontiac, MI 48341-1043 Petitioner name Court telephone no. (248) 858-0581 DOB Address and telephone no. where court can reach petitioner Respondent name, address, and telephone no. DOB or Age v 1. The petitioner and respondent: have a child in common. have or had a dating relationship reside or resided in the same household. The respondent is between 10 and 17 years of age, is unemancipated, and is not the minor child of the petitioner. The petitioner is less than 18 years of age, is unemancipated, and is not the minor child of the respondent. 2. 3. 4. a. There are are not Case number b. There other pending actions in this or any other court regarding the parties. Name of court and county are Case number are not Name of judge orders/judgements entered by this or any other court, regarding the parties. Name of court and county Name of judge 5. I need a personal protection order because:Explain what has happened (attach additional sheets) 6. I ask the court to grant a personal protection order prohibiting the respondent from: a. entering onto the property where I live. I state that either I or my parent, guardian, or custodian have a property interest in the premises; I am married to the respondent; or the respondent or his/her parent, guardian, or custodian has no property interest in the premises. b. entering onto the property at c. assaulting, attacking, beating, molesting or wounding. d. removing the minor children from the petitioner who has legal custody, except as allowed by a custody or parenting time order as long as removal of the children does not violate other conditions of the personal protection order. e. stalking as defined under MCL 750.411h and MCL 750.411i which includes but is not limited to: following me or appearing within my sight. appearing at my workplace or residence. sending mail or other communications to me. contacting me by telephone. approaching or confronting me in a public place or on private property. entering onto or remaining on property owned, leased, or occupied by me. placing an object on or delivering an object to property owned, leased, or occupied by me. f. interfering with efforts to remove my children/personal property from premises solely owned/leased by the respondent. g. threatening to kill or physically injure . h. interfering with me at my place of employment or education or engaging in conduct that impairs my employment or educational relationship or environment. i. having access to information in records concerning a minor child of mine and the respondent that will reveal my 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: 7. I make this petition under authority of MCL 600.2950/MCL 600.2950a and ask the court to grant a personal protection order. I request an ex parte order because immediate and irreparable injury, loss, or damage will occur between now and a hearing or because notice itself will cause irreparable injury, loss, or damage before the order can be entered. 8. I have a next friend petitioning for me. I certify that the next friend is not disqualified by statute and is an adult. Date CC 375M (3/09) PETITION Petitioner’s signature MCL 600.2950, MCL 600.2950a, MCL 712a.2H, MCR 3.703 FOR PERSONAL PROTECTION ORDER AGAINST A MINOR (Domestic Relationship), Page 1 American LegalNet, Inc. www.FormsWorkFlow.com