Approved, SCAO STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION COUNTY Court address ORDER FOR REIMBURSEMENT CASE NO. PETITION NO. Court telephone no. 1. In the matter of (name(s), alias(es), DOB) 2. Date of hearing: THE COURT FINDS: 3. Name(s) and relationship(s) to minor(s) Name of minor(s) Judge: Bar no. , of has(have) been found to be financially able to reimburse the court for costs incurred. IT IS ORDERED: 4. Costs and expenses are assessed as follows: a. Court appointed attorney in the amount billed by attorney and approved by court; current charges $ b. Minor's care, clothing, medical, dental, optical, and other needs that the court determines necessary, in the amount of: $ $ c. Court services of: $ d. Other: per per per , beginning Date . . . Date , beginning , beginning Date . 5. Reimbursement for the above charges shall be as follows: shall reimburse Name(s) Date the court at the rate of $ per , beginning Name and address continuing until the balance is paid in full. Payments are payable to . * Please include the case number with payment. 6. Payments shall be applied against assessed charges as follows: Date Judge Do not write below this line - For court use only JC 38 (9/12) ORDER FOR REIMBURSEMENT MCL 712A.17c(8), MCL 712A.18, MCR 3.915(E), MCR 3.916(D) American LegalNet, Inc. www.FormsWorkFlow.com