Approved, SCAO JIS CODE: CMP STATE OF MICHIGAN COMPLAINT (REQUEST FOR ACTION, COUNTY CHILD PROTECTIVE PROCEEDINGS), PAGE 1 JUDICIAL CIRCUIT - FAMILY DIVISION CASE NO. PETITION NO. Court address Court telephone no. 1. In the matter of a. Name Race Sex Date and place of birth Father Other Father Other Father Other Father Other Father Other Father Other Living with: Mother b. Name Race Sex Date and place of birth Living with: c. Name Race Sex Date and place of birth Living with: d. Name Race Sex Date and place of birth Living with: e. Name Race Sex Date and place of birth Living with: f. Name Race Sex Date and place of birth Living with: Mother Mother Mother Mother Mother BASIS FOR REQUEST 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(5), state that fact along with the child's name and the name of the tribe, if known. SOCIAL INFORMATION 3. Father's name R DOB LF C# PF C# Address Home phone Work phone 4. Father's name R DOB LF C# PF C# Address Home phone Work phone 5. Father's name R DOB LF C# PF C# Address Home phone Work phone 6. Father's name R DOB LF C# PF C# Address Home phone Work phone 7. Mother's name R DOB Address Home phone Work phone 8. Guardian's/Legal custodian's name R DOB Address Home phone Work phone 9. Nonparent adult respondent's name DOB Address Home phone Work phone 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 Date Address/Agency Telephone no. MCL 712A.2, MCL 712A.11, MCR 3.903(A)(9), MCR 3.963(A) JC 02 (3/10) 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 CASE NO. COMPLAINT (REQUEST FOR ACTION, PETITION NO. CHILD PROTECTIVE PROCEEDINGS), PAGE 2 Court address Court telephone no. 1. 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 conclude that the health, safety, or welfare of the child(ren) was endangered. 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 notified attempted notified attempted notified attempted notified attempted 15. Name 16. Name 17. Name STATEMENT OF ALLEGATIONS Methods used Date Time Methods used Date Time Methods used Date Time Methods used Date Time 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 (3/10) COMPLAINT (REQUEST FOR ACTION, CHILD PROTECTIVE PROCEEDINGS), PAGE 2 American LegalNet, Inc. www.FormsWorkFlow.com