Approved, SCAO STATE OF MICHIGAN JUDICIAL DISTRICT JUDICIAL CIRCUIT COUNTY PROBATE Court address CASE NO. ORDER OF DISQUALIFICATION/REASSIGNMENT Court telephone no. Plaintiff name(s) and address(es) Defendant name(s) and address(es) v Plaintiff's attorney, bar no., address, and telephone no. Defendant's attorney, bar no., address, and telephone no. In the matter of IT IS ORDERED: on motion of , on my own motion, am disqualified under MCR 2.003 from hearing this case and I am requesting assignment of another judge for the following reason: Bar no. I, Hon. , 1. I am biased or prejudiced for or against a party or attorney. 2. I have, based on objective and reasonable perceptions, a serious risk of actual bias impacting the due process rights of a party as enunciated in Caperton v Massey, 556 US 868; 129 S Ct 2252; 173 L Ed 2d 1208 (2009). 3. I believe, based on objective and reasonable perceptions, my continued assignment would create an appearance of impropriety. 4. I have personal knowledge of disputed evidentiary facts concerning the proceeding. 5. I have been consulted or employed as an attorney in the matter in controversy. 6. I was a partner of a party, attorney for a party, or a member of a law firm representing a party within the preceding two years. 7. I know that I, individually or as a fiduciary, or my spouse, parent, or child wherever residing, or any other member of my family residing in my household, have more than a de minimis economic interest in the subject matter in controversy that could be substantially impacted by the proceeding. 8. I or my spouse, or a person within the third degree of relationship to either of us, or the spouse of such a person: (i) is a party to the proceeding, or an officer, director, or trustee of a party; (ii) is acting as a lawyer in the proceeding; (iii) is known by me to have a more than de minimis interest that could be substantially affected by the proceeding; or (iv) is to my knowledge likely to be a material witness in the proceeding. 9. Other: (specify) Date Judge Bar no. MC 264 (3/12) ORDER OF DISQUALIFICATION/REASSIGNMENT MCR 2.003, MCR 8.111(C) American LegalNet, Inc. www.FormsWorkFlow.com ADDITIONAL DISQUALIFICATIONS NOTE: If there are not enough signature slots, attach additional sheets. The undersigned judge(s) is/are also disqualified and refer by number to the reason printed on the front of this form. NOTE: IF REASON 9 IS ENTERED, THE COMMENT SECTION MUST BE COMPLETED. REASON 1-9 DATE SIGNATURE COMMENT REQUEST FOR REFERRAL TO SCAO All of the judges of this court have disqualified themselves and have signed this order, indicating their reason for disqualification pursuant to MCR 2.003. The designated Visiting Judge Clerk shall submit a copy of this order, ALONG WITH THE REQUEST FOR ASSIGNMENT, to the appropriate State Court Administrative Office to have another judge assigned to hear this case pursuant to MCR 2.003(D)(4). Date Chief Judge Bar no. INTERNAL REASSIGNMENT REQUEST Judge Bar no. has been chosen by lot or local administrative order from the judges not disqualified in this case. I request that this case be reassigned to this judge. Date Court Administrator or Clerk of the Court Reassignment approved as requested. Date Chief Judge Bar no. American LegalNet, Inc. www.FormsWorkFlow.com