Free mc282.pmd - Michigan

Approved, SCAO

STATE OF MICHIGAN JUDICIAL DISTRICT JUDICIAL CIRCUIT COUNTY PROBATE
Court address

CASE NO. DOMESTIC VIOLENCE SCREENING FOR REFERRAL TO MEDIATION
Court telephone no.

Plaintiff's name

Defendant's name

v
Plaintiff's attorney, bar no., address, and telephone no. Defendant's attorney, bar no., address, and telephone no.

Note: If you have an attorney, this form should be completed with your attorney. Please return this completed form to the ADR clerk at the above court address within 7 business days. Instructions: If there are any actions involving you or the other party, specify the names of the persons involved, the case number, the name of the court where the action was filed, including the county and state. If there are no actions, write "NONE." 1. I am aware of the following personal protection actions involving myself and/or the other party:

2. I am aware of the following domestic violence criminal actions involving myself and/or the other party:

3. I am aware of the following pending child protective (abuse/neglect) actions involving myself and/or the other party:

Date MC 282 (3/08)

Signature

DOMESTIC VIOLENCE SCREENING FOR REFERRAL TO MEDIATION