Approved, SCAO Original - Court 1st copy - Law enforcement agency (file) (green) 2nd copy - Respondent (blue) 3rd copy - Petitioner (pink) 4th copy - Return (yellow) 5th copy - Return (goldenrod) STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY Court address ORI MIPetitioner's name CASE NO. PERSONAL PROTECTION ORDER AGAINST A MINOR (NONDOMESTIC), PAGE 1 EX PARTE Court telephone no. A Respondent's name, address, and telephone no. Address and telephone no. where court can reach petitioner v B Full name of respondent (type or print) * Height Weight Race * Sex * Date of birth or age* Hair color Eye color Driver's license number (if known) 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) Address and telephone no. if different from above Full name of respondent's parent, guardian, custodian (type or print) Address and telephone no. if different from above Date: 1. This order is entered THE COURT FINDS: Judge: Bar no. without a hearing. after hearing. 2. A petition requesting an order to restrain conduct prohibited under MCL 750.411h and MCL 750.411i and/or MCL 750.411s has been filed under the authority of MCL 600.2950a. 3. The respondent is less than 18 years of age, 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 respondent. 5. 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. Respondent committed the following acts of willful, unconsented contact: (State the reasons for issuance.) IT IS ORDERED: 7. Name is prohibited from a. stalking as defined under MCL 750.411h and MCL 750.411i, which includes but is not limited to following or appearing within sight of the petitioner. appearing at the workplace or the residence of the petitioner. approaching or confronting the petitioner in a public place or on private property. entering onto or remaining on property owned, leased, or occupied by the petitioner. sending mail or other communications to the petitioner. contacting the petitioner by telephone. placing an object on or delivering an object to property owned, leased, or occupied by the petitioner. threatening to kill or physically injure Name purchasing or possessing a firearm. other: (PLEASE SEE OTHER SIDE) . CC 380M (3/12) PERSONAL PROTECTION ORDER AGAINST A MINOR (NONDOMESTIC), Page 1 MCL 600.2950a, MCL 712A.2(h), MCR 3.705, MCR 3.706 American LegalNet, Inc. www.FormsWorkFlow.com Approved, SCAO STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY Court address ORI MIPetitioner's name A PERSONAL PROTECTION ORDER AGAINST A MINOR (NONDOMESTIC), PAGE 2 EX PARTE B CASE NO. Court telephone no. v Respondent's name IT IS FURTHER ORDERED: 7. (continued from page 1) b. posting a message through the use of any medium of communication, including the Internet or a computer or any electronic medium, pursuant to MCL 750.411s. 8. a. If the respondent is 17 years of age or more, violation of this order subjects the 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 respondent is less than 17 years of age, violation of this order subjects the 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 respondent violates this order in a jurisdiction other than this state, 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 who will enter it into the LEIN. Name of law enforcement agency , 11. The respondent may file a motion to modify or terminate this order. If this is an ex parte order, a motion to modify or terminate this order and a request for a hearing must be made within 14 days after the respondent has been served or has received actual notice of this 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 Judge CC 380M (3/12) PERSONAL PROTECTION ORDER AGAINST A MINOR (NONDOMESTIC), Page 2 American LegalNet, Inc. www.FormsWorkFlow.com PROOF OF SERVICE Personal Protection Order Against a Minor (Nondomestic) 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: (notarization 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: (notarization required) I served a copy of the personal protection order against a minor by personal service on: 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 b