Approved, SCAO JIS CODE: CMP STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION COUNTY COMPLAINT (REQUEST FOR ACTION, DELINQUENCY PROCEEDINGS), PAGE 1 CASE NO. PETITION NO. Court address Court telephone no. Last First Middle 1. In the matter of 2. Date of birth 3. Sex 4. Race 5. Member of or eligible for membership in American Indian Tribe or Band 6. Height 7. Weight 8. Eye color 9. Hair color 10. School/District 11. Municipality and county of legal residence BASIS FOR REQUEST 12. Brief statement of the allegations and basis for any request for court-ordered apprehension, including the citations and date, time, and location of offense Operator/Chauffeur driver license Commercial driver license No license Vehicle type 13. Codefendant(s): name(s), alias(es), DOB SOCIAL INFORMATION 14. Father's name Address Home phone Work phone 15. Mother's name Address Home phone Work phone 16. Stepparent's name Address Home phone Work phone 17. Guardian/Legal custodian's name Address Home phone Work phone 18. Divorced? No Date of divorce Yes Place of divorce: (county, state) 19. Custody to: Father Mother Other (name and address) : 20. Juvenile living with: Father Mother Stepfather Stepmother Other: REQUEST 21. I REQUEST a. a petition be authorized. b. the court review the information and make an appropriate disposition. c. an order be issued to apprehend the juvenile pending the preliminary hearing pursuant to MCR 3.933(B). permission to enter the premises at . d. an order be issued to detain the juvenile pending the preliminary hearing pursuant to MCR 3.934(B). 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 Date Address/Agency Telephone no. MCL 712A.2, MCL 712A.11, MCL 712A.14, MCL 712A.15, MCR 3.903(A)(9), MCR 3.933(A), MCR 3.934, MCR 3.983 JC 01 (9/06) COMPLAINT (REQUEST FOR ACTION, DELINQUENCY PROCEEDINGS), PAGE 1 American LegalNet, Inc. www.FormsWorkflow.com Approved, SCAO JIS CODE: CMP STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION COUNTY COMPLAINT (REQUEST FOR ACTION, DELINQUENCY PROCEEDINGS), PAGE 2 CASE NO. PETITION NO. Court address Court telephone no. Last First Middle 1. In the matter of CUSTODY Fill out completely 22. Basis for apprehension by police without court order 23. Check if applicable The officer had reason to believe that because of the nature of the offense, the interest of the juvenile or the interest of the public would not be protected by release of the juvenile. Parent/guardian/legal custodian could not be located or refused to take custody of the juvenile. Miranda warning given Offense admitted Offense denied Parents/Guardian/Legal custodian present Attorney present Fingerprints taken Photograph taken Line-up held 24.Release and recognizance I acknowledge that the juvenile has been released to my custody, and I promise to bring the juvenile to the court upon notice. Date Signature Relationship to juvenile NOTIFICATION TO PARENT, GUARDIAN, OR LEGAL CUSTODIAN 25. 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. 26. Name notified attempted notified attempted notified attempted notified attempted 27. Name 28. Name 29. Name Methods used Date Time Methods used Date Time Methods used Date Time Methods used Date Time ADDITIONAL COMMENTS MCL 712A.2, MCL 712A.11, MCL 712A.14, MCR 3.903(A)(9), MCR 3.933(A), MCR 3.934, MCR 3.983 JC 01 (9/06) COMPLAINT (REQUEST FOR ACTION - DELINQUENCY PROCEEDINGS), PAGE 2 American LegalNet, Inc. www.FormsWorkflow.com