STATE OF MICHIGAN 6th JUDICIAL CIRCUIT COUNTY OF OAKLAND 1200 N. TELEGRAPH RD, PONTIAC, MI 48341 VERIFIED STATEMENT RE: PPO ACTION Age V RESPONDENT CASE NO. (248) 975-5911 PETITIONER Age Have you or respondent ever used any other names (now or in the past)? What county do you live in? Respondent lives in Do you or have you lived together: Yes How do you know the person you are filing against? Yes No. If yes, please list them. County. No. Do you and respondent have child(ren) together NAME OF CHILD Yes No If yes, list the children you have together. CURRENT ADDRESS DATE OF BIRTH 1. 2. 3. (ATTACH EXTRA SHEETS IF NECESSARY) No if no, check one: Were you married to respondent when the child(ren) were born? Yes There has been a legal order of paternity entered. Case number: A paternity case has been filed and is pending. Case number The father legally acknowledged paternity. There has been no legal acknowledgment of paternity. Is there a custody or parenting time order in effect regarding child(ren) that you and respondent have together? Yes If yes, fill out attached worksheet. No If you and respondent have child(ren) together, fill out the attached worksheet regarding custody and parenting time. List all other children that either of you have Have you or respondent ever asked for a Personal Protection Order in another county? What county When Why Have you or respondent ever been to court in another county? Yes What county When Why Yes No No Does the respondent have a license to carry a firearm? Yes No Is the respondent employed or in training for a position which will require him/her to carry a firearm? Is the respondent an employee of a law enforcement agency? Yes No. If yes, which agency? Is the respondent an employee of the Department of Corrections? Yes No. If yes, which facility? Yes No 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 VERIFIED STATEMENT-2 (101906) American LegalNet, Inc. www.FormsWorkFlow.com