Approved, SCAO PCS CODE: OTC TCS CODE: OTC STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION COUNTY Court address ORDER TO TAKE CHILD(REN) INTO PROTECTIVE CUSTODY AND PLACE (CHILD PROTECTIVE PROCEEDINGS) EX PARTE CASE NO. PETITION NO. Court telephone no. 1. In the matter of name(s), alias(es), DOB (see reverse side for other identifying information) 2. Date of entry of order: Judge/Referee: Bar no. THE COURT FINDS: 3. a. The child(ren) has/have already been removed from the parent(s), guardian, or legal custodian and is/are absent without leave from court-ordered placement. b. Under MCL 712A.2(b) and MCR 3.963(B), MCR 3.974(C)(1), there is reasonable cause to believe that: 1) 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 immediate removal from those surroundings is necessary to protect the child(ren)'s health and safety. 2) The circumstances warrant issuing this order. 3) Continuing to reside in the home is contrary to the child(ren)'s welfare because: (Specify.) 4) No remedy other than protective custody is reasonably available to protect the child(ren). 5) Consistent with the circumstances, reasonable efforts were made to prevent or eliminate the need for removal of the child(ren) as follows: (Specify.) 4. a. Reasonable efforts are not required to prevent or eliminate the child(ren)'s removal from the home due to (See note below.) the mother father subjecting the child(ren) to the aggravated circumstance(s) of as provided in section MCL 722.638(1) and (2), and as evidenced by the mother's father's conviction for murder of another child of the parent. the mother's father's conviction for voluntary manslaughter of another child of the parent. the mother's father's conviction for aiding or abetting in the murder or manslaughter of another child of the parent, attempting to murder the child(ren) or another child of the parent, or conspiring or soliciting to commit the murder of the child(ren) or another child of the parent. the mother's father's conviction for felony assault that resulted in serious bodily injury to the child(ren) or another child of the parent. the mother's father's involuntary termination of parental rights to a sibling of the child(ren). the mother father being required to register under the Sex Offender Registration Act. b. Reasonable efforts to preserve and reunify the family to make it possible for the child(ren) to safely return home are not required because the parent subjected the child or another child of the parent to one of the circumstances stated above. OR still recommended because: . NOTE: When item 4 is checked, schedule a permanency planning hearing within 28 days of this determination. 5. The child(ren) is/are Indian as defined in MCR 3.002(12), subject to the exclusive jurisdiction of a tribal court but temporarily located off the reservation, and removal of the child(ren) is necessary to prevent imminent physical damage or harm to the child(ren). See additional pages. JC 05b (9/16) American LegalNet, Inc. www.FormsWorkFlow.com ORDER TO TAKE CHILD(REN) INTO PROTECTIVE CUSTODY AND PLACE MCL 712A.2(b), MCL 712A.14a, (CHILD PROTECTIVE PROCEEDINGS) MCL 712A.19a(2), MCR 3.963(B), (C), (D)(2), MCR 3.974(C)(1), MCR 3.979(F)(2) Order to Take Child(ren) into Protective Custody and Place (9/16) Page of Case No. Petition No. IT IS ORDERED: TO: Specify whether child protective services worker, an officer, or other person deemed suitable by the court under MCR 3.963(B)(1) 6. The child(ren) shall be taken into protective custody and a. placed with/returned to the department for care and supervision. b. placed at treatment until medically released to for placement at Placement shall continue until resumption of the next scheduled hearing. 7. To effect this order you are authorized to enter the premises located at . 8. The parent(s), guardian, or legal custodian of the child(ren) shall be directed to appear for a preliminary hearing in this matter to be held on Date for medical observation and . at Time (if known) at Location . (Item 8 is not applicable for orders to take children into custody who are absent without leave from court-ordered placement.) 9. This authorization to enter the premises and take the child(ren) into protective custody expires Enter on LEIN . Recommended by: Referee signature Date Note: Referee recommendation not required if acting under MCL 712A.14a(3). Date Judge/Referee Note: To parent(s), guardian, or legal custodian: If you require special accommodations to use the court because of a disability or if you require a foreign language interpreter to help you fully participate in court proceedings, please contact the court immediately to make arrangements. Use Note: A referee may issue an interim placement order pending a preliminary hearing. Reference Note: The term "department" refers to the Department of Health and Human Services. American LegalNet, Inc. www.FormsWorkFlow.com Order to Take Child(ren) into Protective Custody and Place (9/16) Identifying information, Custody Statement, and Record of Notification Case No. Petition No. IDENTIFYING INFORMATION Name Name Name Name Home address Father's name Mother's name Pickup radius Statewide Other: Address Address Race Race Race Race Sex Sex Sex Sex Height Height Height Height City City City Court ORI MI Weight Weight Weight Weight Hair color Eye color Hair color Eye color Hair color Eye color Hair color Eye color State State State Zip Zip Zip Date of birth Date of birth Date of birth Date of birth Telephone number Telephone number Telephone number Reason for removal is stated in item 3 on page 1 of the order to take child(ren) into protective custody. CUSTODY STATEMENT AND RECORD OF NOTIFICATION 1. I certify and return that I have taken into custody on to 2. I Date Child(ren)'s name(s) at Time and have delivered the child(ren) . Place of temporary placement notified attempted to notify the parent(s), guardian, or legal custodian listed below that the child(ren) has/have been Date taken into protective custody and that a preliminary hearing or an emergency removal hearing will be held on at Time at Location . METHODS USED (reasons for failure to notify must be noted) NAME Father Mother Guardian/Legal custodian Other DATE TIME I declare that this custody statement has been examined by me and that its contents are true to the best of my information, knowledge, and belief. Date Signature Agency na