Approved, SCAO Original - Court 1st copy - Law enforcement agency/Sheriff 2nd copy - Defendant/Juvenile 3rd copy - Prosecuting attorney 4th copy - Return STATE OF MICHIGAN JUDICIAL DISTRICT JUDICIAL CIRCUIT Court address CASE NO. ORDER FOR DNA SAMPLE Court telephone no. The State of Michigan THE PEOPLE OF v Defendant/Juvenile name, address, and telephone no. CTN SID DOB Juvenile In the matter of 1. On Date , the defendant/juvenile was arrested, convicted of, or found responsible for violation(s) , as prescribed in MCL 28.176, which or attempted violation(s) of require(s) that a DNA sample be taken. 2. The defendant/juvenile is IT IS ORDERED: 3. The defendant/juvenile shall provide a DNA sample to the on bond. incarcerated in . Name of investigating law enforcement agency/Sheriff to be forwarded to the Department of State Police in accordance with MCL 712A.18k, 28.171 to 28.176, 750.520m, and Department of State Police Rules by Sentence date . 4. The investigating law enforcement agency/sheriff named above shall file a return with the court that the sample was either taken or not required because a sample has already been taken. Date Judge Bar no. CERTIFICATION AND RETURN I certify and return that a DNA sample of the defendant/juvenile was taken and forwarded to the Department of State Police as ordered above. was not taken because the Department of State Police already has a DNA sample of the defendant/juvenile. Date Law enforcement agent/Sheriff MC 283 (6/15) ORDER FOR DNA SAMPLE American LegalNet, Inc. www.FormsWorkFlow.com MCL 712A.18k, MCL 750.520m