Approved, SCAO Original - Court 1st copy - Respondent 2nd copy - Law Enforcement Agency Copies as needed PCS CODE: OAA TCS CODE: ORH STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION COUNTY Court address ORDER REMOVING ALLEGED ABUSER FROM CHILD'S HOME (CHILD PROTECTIVE PROCEEDINGS) CASE NO. PETITION NO. Court telephone no. 1. In the matter of name(s), alias(es), DOB Regarding alleged abuser Height Weight Race Last name First name Sex Middle initial Date of birth or age Other identifying information Relationship to child Hair color Eye color Driver's license no. 2. Date of hearing: Judge/Referee: Bar no. 3. Notice of hearing was given as required by law. THE COURT FINDS: 4. A petition alleging abuse of the child(ren) has been authorized and there is probable cause to believe the parent, guardian, legal custodian, or other person committed the alleged abuse. 5. The alleged abuser's presence in the home presents a substantial risk of harm to the child(ren)'s life, physical health, or mental well-being. IT IS ORDERED: 6. The alleged abuser named above shall a. leave the home at until further order of the court and have no contact with the child(ren) named above except as follows: b. pay $ as appropriate support to maintain a suitable home environment for the child(ren). Name of local law enforcement agency c. surrender any firearms or potentially dangerous weapons to 7. Other: . 8. This order is valid from until and is effective when the alleged abuser receives notice. A violation of the terms and conditions subjects the alleged abuser to criminal contempt of court. If found guilty of violating this order, the alleged abuser may be jailed for up to 90 days and fined up to $500.00. 9. This order shall be entered into LEIN. Recommended by: Referee signature Date Date Judge Do not write below this line - For court use only American LegalNet, Inc. www.FormsWorkFlow.com MCL 712A.13a, MCL 764.15f JC 65 (9/16) ORDER REMOVING ALLEGED ABUSER FROM CHILD'S HOME (CHILD PROTECTIVE PROCEEDINGS)