Approved, SCAO JIS CODE: ROC STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION COUNTY Court address REQUEST AND ORDER FOR COURT-APPOINTED ATTORNEY CASE NO. PETITION NO. Court telephone no. 1.In the matter of name(s), alias(es), DOB REQUEST 2. I do not have funds to hire an attorney and I request that the court appoint an attorney to represent me. I am a minor who has no income or assets. a parent who is a respondent in a child protective proceeding. 3. Attached is my completed form JC 34, Financial Statement. (A separate financial statement must be completed for each respondent.) 4. I understand that the court may assess costs of representation against me or against a person responsible for my support. Date Signature of minor/respondent Name (type or print) Address City, state, zip Telephone no. ORDER THE COURT FINDS: 5. The minor and those responsible for the support of the minor are financially unable to retain an attorney and the minor does not waive an attorney. 6. On the basis of the record, including written financial statements, the respondent is financially unable to retain an attorney and does not waive an attorney. IT IS ORDERED: 7. Name of attorney Address City, state, zip Telephone no. Bar no. is appointed to represent the requesting party. 8. The request for a court-appointed attorney is denied because . Date Judge Bar no. Do not write below this line - For court use only JC 102 (9/09) REQUEST AND ORDER FOR COURT-APPOINTED ATTORNEY American LegalNet, Inc. www.FormsWorkFlow.com MCR 3.915