3rd copy - Petitioner (pink) 4th copy - Return (yellow) 5th copy - Return (goldenrod) Original - Court 1st copy - Law enforcement agency (file) (green) 2nd copy - Respondent (blue) Approved, SCAO STATE OF MICHIGAN PERSONAL PROTECTION ORDER AGAINST A JUDICIAL CIRCUIT MINOR (NONDOMESTIC SEXUAL ASSAULT), PAGE 1 COUNTY EX PARTE CASE NO. Court address ORI MI- A Court telephone no. Petitioner's name Respondent's name, address, and telephone no. v Address and telephone no. where court can reach petitioner B Full name of respondent (type or print) * Height Weight Race * Driver's license number (if known) Sex * Date of birth or age* Hair color Eye color Other identifying information *These items must be filled in for the police/sheriff to enter on LEIN; the other items are not required but are helpful. C Full name of respondent's parent, guardian, custodian (type or print) Full name of respondent's parent, guardian, custodian (type or print) Address and telephone no. if different from above Address and telephone no. if different from above Date: Judge: 1. This order is entered without a hearing. Bar no. after hearing. THE COURT FINDS: 2. A petition has been filed requesting an order under MCL 600.2950a(2). 3. The respondent is less than 18 years of age. The minor respondent is unemancipated and is not the minor child of the petitioner. 4. The petitioner is less than 18 years of age, is unemancipated, and is not the minor child of the minor respondent. 5. The petitioner requested an ex parte order, which should be entered without notice because irreparable injury, loss, or damage will result from delay required to give notice or notice itself will precipitate adverse action before an order can be issued. 6. The minor respondent has been subject to an order of disposition or other adjudication based on sexual assault of the petitioner as follows: The petitioner has a reasonable apprehension of sexual assault because the minor respondent has sexually assaulted the petitioner or threatened the petitioner with sexual assault. The petitioner is a minor and the minor respondent has been subject to an order of disposition or other adjudication based on furnishing obscene material to the petitioner in violation of MCL 750.142 or a substantially similar law from another jurisdiction as follows: The petitioner is a minor and the minor respondent has furnished obscene material to the petitioner. IT IS ORDERED: 7. is prohibited from entering onto property where the petitioner lives. entering onto property at . threatening to sexually assault, kill, or physically injure the petitioner or a named individual. purchasing or possessing a firearm. interfering with the petitioner's efforts to remove the petitioner's children or personal property from premises that are solely owned or leased by the respondent. (PLEASE SEE OTHER SIDE) MCL 600.2950a, MCR 3.705, MCR 3.706, 18 USC 922(g)(8)(c) CC 396M (3/12) PERSONAL PROTECTION ORDER AGAINST A MINOR (NONDOMESTIC SEXUAL ASSAULT), Page 1 American LegalNet, Inc. www.FormsWorkFlow.com Approved, SCAO STATE OF MICHIGAN PERSONAL PROTECTION ORDER AGAINST A JUDICIAL CIRCUIT MINOR (NONDOMESTIC SEXUAL ASSAULT), PAGE 2 COUNTY EX PARTE Court address ORI MI- CASE NO. Court telephone no. Petitioner's name v Respondent's name IT IS FURTHER ORDERED: 7. (continued from page 1) interfering with the petitioner at the petitioner's place of employment or education, or engaging in conduct that impairs the petitioner's employment or educational relationship or environment. following the petitioner or appearing within the petitioner's sight. approaching or confronting the petitioner in a public place or on private property. appearing at the petitioner's workplace or residence. entering onto or remaining on property owned, leased, or occupied by the petitioner. contacting the petitioner by telephone. sending mail or electronic communications to the petitioner. placing an object on or delivering an object to property owned, leased, or occupied by the petitioner. posting an electronic message with the intent to cause others to contact the petitioner in a way that would make the petitioner feel terrorized, frightened, intimidated, threatened, harassed, or molested. any other specific act or conduct that imposes upon or interferes with the petitioner's personal liberty or that causes a reasonable apprehension of violence or sexual assault, as follows: 8. a. If the minor respondent is 17 years of age or more, violation of this order subjects the minor respondent to immediate arrest and to the civil and criminal contempt powers of the court. If found guilty of a violation, the respondent shall be imprisoned for not more than 93 days and may be fined not more than $500.00. b. If the minor respondent is less than 17 years of age, violation of this order subjects the minor respondent to immediate apprehension or being taken into custody. If found guilty of a violation, the respondent shall be subject to the dispositional alternatives listed in MCL 712A.18. 9. This order is effective when signed, enforceable immediately, and remains in effect until . This order is enforceable anywhere in this state by any law enforcement agency when signed by a judge, and upon service, may also be enforced by another state, an Indian tribe, or a territory of the United States. If the minor respondent violates this order in a jurisdiction other than this state, the minor respondent is subject to enforcement and penalties of the state, Indian tribe, or United States territory under whose jurisdiction the violation occurred. 10. The court clerk shall file this order with , Name of law enforcement agency who will enter it into the LEIN. 11. For an ex parte order, the minor respondent may file a motion to modify or terminate the order within 14 days after being served with or receiving actual notice of the order. Forms and instructions are available from the clerk of the court. 12. A motion to extend the order must be filed 3 days before the expiration date in item 9 or a new petition must be filed. 13. Other: Date and time issued CC 396M (3/12) Judge PERSONAL PROTECTION ORDER AGAINST A MINOR (NONDOMESTIC SEXUAL ASSAULT), Page 2 American LegalNet, Inc. www.FormsWorkFlow.com PROOF OF SERVICE Personal Protection Order Against a Minor (Nondomestic Sexual Assault) Case No. TO PROCESS SERVER: You must serve the personal protection order against a minor and file proof of service with the court clerk. If you are unable to complete service, you must return this original and all copies to the court clerk. CERTIFICATE / AFFIDAVIT OF SERVICE / NONSERVICE OR OFFICER CERTIFICATE I certify that I am a sheriff, deputy sheriff, bailiff, appointed court officer, or attorney for a party [MCR 2.104(A)(2)], and that: (notary not required) AFFIDAVIT OF PROCESS SERVER Being first duly sworn, I state that I am a legally competent adult who is not a party or an officer of a corporate party, and that: (notary required) I served a copy of the personal protection order against a minor by: personal service registered mail, delivery restricted to the respondent and the parent(s), guardian(s), or custodian(s) of the respondent (return receipt attached) on: Name of respondent Complete address of service Day, date, time Name of parent/guardian/custodian Complete address of service Day, date, time Name of parent/guardian/custodian Complete address of service Day, date, time Law enforcement agency Complete address of service Day, date, time I have personally attempted to serve a copy of the personal protection order against a minor on the following respondent and have been unable to complete service. Respondent's name Complete address of service I declare that the statements above are true to the best of my information, knowledge, and belief. Service fee Miles traveled Fee $ Incorrect address fee Name (type or print) $ Miles traveled Fee $ TOTAL FEE $ Signature $ Title Subscribed and sworn to before me on , County, Michigan. Date My commission expires: Signature: Date Deputy court clerk/Notary public Notary public, State of Michigan, County of ACKNOWLEDGMENT OF SERVICE I acknowledge that I have received a copy of the personal protection order against a minor on Day, date, time Signature of respondent's parent/guardian/custodian . Signature of respondent Signature of respondent's parent/guardian/custodian MCR 2.105(A) American LegalNet, Inc. www.FormsWorkFlow.com Form CC 396M PERSONAL PROTECTION ORDER AGAINST A MINOR (NONDOMESTIC SEXUAL ASSAULT) Use this form if you filled out form CC 395M, Petition for Personal Protection Order Against a Minor (Nondomestic Sexual Assault). American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR COMPLETING "PERSONAL PROTECTION ORDER AGAINST A MINOR (NONDOMESTIC SEXUAL ASSAULT)" Please print neatly. Items A through C must be completed before you give this form to the court clerk. Please read the instruction for each item. Then fill in the correct information for that item on the form. A Fill in the "petitioner" and "respondent" the same way you did on form CC 397. If you want the address and telephone number where you live to be kept from the respondent, do not write that address here. Put in the address of a relative or friend or a post office box where the court can contact you. B Write in the respondent's name and as much of the other information about the respondent as you know. This information will help the police identify the respondent if he or she disobeys the restraining order. Be sure to identify the respondent accurately. The race, sex, and date of birth are required for law enforcement to enter an order on the Law Enforcement Information Network (LEIN). C Write in the name(s) and address(es) of the respondent's parent(s), guardian(s), or custodian(s). The court will complete the rest of this form. NOTE: There are only six copies of this form. You will need to make extra copies of this form for each parent, guardian, or custodian of the respondent. You must read the booklet "Instructions for Personal Protection Orders" for directions on the legal process. • If you asked for an ex parte order (order without a hearing), read pages 3 and 4 of the booklet. • If you did not ask for an ex parte order or the judge refuses to sign an ex parte order, read pages 5 and 6 of the booklet. American LegalNet, Inc. www.FormsWorkFlow.com