Free Order for Reimbursement - Michigan

Approved, SCAO

STATE OF MICHIGAN
JUDICIAL CIRCUIT - FAMILY DIVISION

COUNTY
Court address

ORDER FOR REIMBURSEMENT

CASE NO. PETITION NO.

Court telephone no.

1. In the matter of
(name(s), alias(es), DOB)

2. Date of hearing: THE COURT FINDS: 3.
Name(s) and relationship(s) to minor(s) Name of minor(s)

Judge:
Bar no.

, of has(have) been found to be financially able to reimburse the court for costs incurred.

IT IS ORDERED: 4. Costs and expenses are assessed as follows: a. Court appointed attorney in the amount billed by attorney and approved by court; current charges $ b. Minor's care, clothing, medical, dental, optical, and other needs that the court determines necessary, in the amount of: $ $ c. Court services of: $ d. Other: 5. Reimbursement for the above charges shall be as follows: shall reimburse
Name(s)

.

per per per

, beginning
Date

. .
Date

, beginning , beginning
Date

.

the court at the rate of $

per

, beginning
Date Name and address

continuing until the balance is paid in full. Payments are payable to . Please include the case number with payment. 6. Payments shall be applied against assessed charges as follows:

Date

Judge

Do not write below this line - For court use only

JC 38 (6/03)

ORDER FOR REIMBURSEMENT

MCL 712A.17c(8), MCL 712A.18, MCR 3.915(E), MCR 3.916(D)