Approved, SCAO JIS CODE: CMP STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION COMPLAINT (REQUEST FOR ACTION, COUNTY CHILD PROTECTIVE PROCEEDINGS), PAGE 1 CASE NO. PETITION NO. Court address Court telephone no. 1. In the matter of a. b. c. d. e. f. Name Name Name Name Name Name Race Race Race Race Race Race Sex Sex Sex Sex Sex Sex Date and place of birth Date and place of birth Date and place of birth Date and place of birth Date and place of birth Date and place of birth Living with: Mother Living with: Mother Living with: Mother Living with: Mother Living with: Mother Living with: Mother BASIS FOR REQUEST Father Other Father Other Father Other Father Other Father Other Father Other 2. See page 2 for a statement of the allegations, including the citations and date, time, and location of alleged abuse or neglect, and the basis for any request for court-ordered protective custody. If any child is Indian as defined in MCR 3.002(12), state that fact along with the child's name and the name of the tribe, if known. SOCIAL INFORMATION 3. 4. 5. 6. 7. 8. 9. Father's name Father's name Father's name Father's name Mother's name R DOB R DOB R DOB R DOB R DOB R DOB DOB LF C# PF C# Address LF C# PF C# Address LF C# PF C# Address LF C# PF C# Address Address Address Address Home phone Home phone Home phone Home phone Home phone Home phone Home phone Work phone Work phone Work phone Work phone Work phone Work phone Work phone Guardian's/Legal custodian's name Nonparent adult respondent's name Instructions for items 3 through 8. If the father/mother/guardian or legal custodian is a respondent, place a check mark in the column R. If the father is a legal father, indicate for which child(ren) by placing the corresponding numbers 1a, 1b, 1c, etc. in the column LF C#. If the father is a putative father, indicate for which child(ren) by placing the corresponding numbers 1a, 1b, 1c, etc. in the column PF C#. 10. An action within the jurisdiction of the family division of circuit court involving the family or family members of the minor has been previously filed in Court, Case Number , was assigned to Judge , and remains is no longer pending. REQUEST 11. I REQUEST: a. a petition be authorized. b. the court review the information and make an appropriate disposition. c. an order be issued to take the child into protective custody pending a preliminary hearing pursuant to MCR 3.963(B). permission to enter the premises at I declare that this complaint has been examined by me and that its contents are true to the best of my information, knowledge, and belief. Complainant's signature Print or type name Address/Agency Date Telephone no. . MCL 712A.2, MCL 712A.11, MCR 3.903(A)(9), MCR 3.963(A) JC 02 (9/13) COMPLAINT (REQUEST FOR ACTION, CHILD PROTECTIVE PROCEEDINGS), PAGE 1 American LegalNet, Inc. www.FormsWorkFlow.com Approved, SCAO JIS CODE: CMP STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION COUNTY Court address CASE NO. COMPLAINT (REQUEST FOR ACTION, PETITION NO. CHILD PROTECTIVE PROCEEDINGS), PAGE 2 Court telephone no. In the matter of CUSTODY Fill out completely 12. Basis for protective custody by police without court order After investigation, the officer had reasonable grounds to believe that the child(ren) is/are at substantial risk of harm or is/are in surroundings that present an imminent risk of harm and the child(ren)'s removal from those surroundings is necessary to protect the child(ren)'s health and safety. The parent(s), guardian, or legal custodian was/were was/were not present. NOTIFICATION TO PARENT, GUARDIAN, OR LEGAL CUSTODIAN 13. I notified or attempted to notify the person(s) listed below about the date, time, and place of the preliminary hearing. The method of contact or attempted contact is described below and includes the date and time of notification for each. 14. Name 15. Name 16. Name 17. Name notified attempted notified attempted notified attempted notified attempted Methods used Methods used Methods used Methods used Date Date Date Date Time Time Time Time STATEMENT OF ALLEGATIONS Provide the physical description for each child including height, weight, eye color, and hair color. MCL 712A.2, MCL 712A.11, MCR 3.903(A)(9), MCR 3.963(A) JC 02 (9/13) COMPLAINT (REQUEST FOR ACTION, CHILD PROTECTIVE PROCEEDINGS), PAGE 2 American LegalNet, Inc. www.FormsWorkFlow.com