Free JC04b.pmd - Michigan

Approved, SCAO

JIS CODE: PET

STATE OF MICHIGAN

JUDICIAL CIRCUIT - FAMILY DIVISION Court address ORI MIa.

CASE NO. PETITION (CHILD PROTECTIVE PROCEEDINGS) PETITION NO. Supplemental COUNTY
Court telephone no.

1. In the matter of (State the name, county of legal residence, race, sex, and date and place of birth of each child, and indicate with whom the child lives.) Name of child and county of legal residence Race Sex Date and place of birth Living with: Father Mother Other b. Name of child and county of legal residence Race Sex Date and place of birth Living with: Father Mother Other c. Name of child and county of legal residence Race Sex Date and place of birth Living with: Father Mother Other d. Name of child and county of legal residence Race Sex Date and place of birth Living with: Father Mother Other 2. The child(ren) named above come(s) within the provisions of MCL 712A.2. See attached sheet for allegations, the reasons why it is contrary to the welfare of the child(ren) for the child(ren) to remain in the home, and the reasonable efforts made to prevent the removal of the child(ren). Member of or eligible for membership in American Indian Tribe or Band as stated in allegations. Military/nonmilitary affidavit attached. 3. An action within the jurisdiction of the family division of circuit court involving the family or family members of the minor has been previously filed in Court, Case Number , was assigned to Judge , and remains is no longer pending. 4. The names and addresses and other relevant information of the parents, guardian, legal custodian, or nearest known relative are as follows: (If the father/mother/guardian or legal custodian is a respondent, place a check mark in the column R. Indicate for which child[ren]
the father is a legal or putative father by placing the corresponding numbers 1a, 1b, 1c, etc. in the column LF C# or column PF C#.) a. Father's name R DOB LF C# PF C# Address Telephone no. b. Father's name c. Father's name d. Father's name Mother's name Guardian's/Legal custodian's name Nearest known relative's name Nonparent adult respondent's name R DOB R DOB R DOB R DOB R DOB DOB DOB LF C# LF C# LF C# PF C# Address PF C# Address PF C# Address Telephone no. Telephone no. Telephone no. Telephone no. Telephone no. Telephone no. Telephone no.

Address Address Address Address

5. I request the court to a. refer the matter to alternative services. b. authorize this petition and take jurisdiction over the child(ren). Further, I request the court to issue an order removing the child(ren) the abuser from the home. c. terminate parental rights of mother. parental rights of father 4a. 4b. I declare that the statements in this petition are true to the best of my information, knowledge, and belief.
Petitioner's signature Print or type name Date Agency/Address City, state, and zip

4c.

4d.

Telephone no.

Approved by:

Prosecutor's signature (optional)

6. A preliminary inquiry and/or hearing has been conducted and the filing of this petition on the child(ren) the following child(ren) on the child(ren) the following child(ren)
Date JC 04b (9/08) Judge/Referee

is authorized. is not authorized.

PETITION (CHILD PROTECTIVE PROCEEDINGS)

Bar no. MCL 712A.2, MCR 3.903(A)(19), MCR 3.926(A), MCR 3.961