Original - Court 1st copy - Prosecuting Attorney Approved, SCAO STATE OF MICHIGAN JUDICIAL DISTRICT JUDICIAL CIRCUIT 2nd copy - Superintendent of public instruction 3rd copy - District, school, or academy CASE NO. DISCLOSURE OF EMPLOYMENT OR CONTRACT IN MICHIGAN SCHOOL SYSTEM Court address Court telephone no. Defendant's name, address, and telephone no. THE PEOPLE OF The State of Michigan v Superintendent of public instruction Michigan Department of Education Attn: Superintendent of Public Instruction PO Box 30008 Lansing, MI 48909 Michigan Compiled Law 380.1230d(2) states that if a person who is employed in any capacity by or is regularly and continuously working under contract in a school district, intermediate school district, public school academy, or nonpublic school enters a plea of guilt or no contest to or is the subject of a finding of guilt by a judge or jury of any crime after having been initially charged with a crime described in MCL 380.1535a(1) or MCL 380.1539b(1), then the person immediately shall disclose to the court, on a form prescribed by the state court administrative office, that he or she is employed by or regularly and continuously working under contract in a school district, intermediate school district, public school academy, or nonpublic school. The person shall immediately provide a copy of the form to the prosecuting attorney in charge of the case, to the superintendent of public instruction, and to the superintendent or chief administrator of the school district, intermediate school district, public school academy, or nonpublic school. In accordance with MCL 380.1230d(2), I, , Name having entered a plea of guilty or no contest or having been found guilty by a judge or jury of a crime, disclose that I am employed by or regularly and continuously working under contract in the school district, intermediate school district, public school academy, or nonpublic school specified below. Name of superintendent or chief administrator Name of district, school, or academy Street address City, state, and zip I understand all of the above. I also understand that I must complete, file with the court, and provide copies of this disclosure to the prosecuting attorney, to the superintendent of public instruction, and to the superintendent or chief administrator for every school district, intermediate school district, public school academy, or nonpublic school that I am employed by or regularly and continuously working in under contract. Date Signature MCL 380.1230d(2), MCL 380.1535a(7) MC 292 (3/08) DISCLOSURE OF EMPLOYMENT OR CONTRACT IN MICHIGAN SCHOOL SYSTEM American LegalNet, Inc. www.FormsWorkflow.com