Approved, SCAO
STATE OF MICHIGAN
JUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY
Court address
REQUEST AND ORDER FOR REVIEW OF REFEREE RECOMMENDATION
CASE NO. PETITION NO.
Court telephone no.
1. In the matter of
(name(s), alias(es), DOB)
REQUEST 2. I request that a judge review the referee recommendations in this matter entered on
Date
.
3. Grounds for review are as follows:
Signature Name (type or print)
Date
Address City, state, and zip Telephone no.
NOTE: This request must be filed with the court within 7 days after the conclusion of the inquiry or hearing or within 7 days after the issuance of the referee's written recommendation (as stated in item 2 above), whichever is later.
ORDER 4. IT IS ORDERED that the referee's recommendations referred to above are stayed pending decision on this review. modified as follows: affirmed. denied.
Date
Judge
Bar no.
Do not write below this line - For court use only
JC 42 (6/03)
REQUEST AND ORDER FOR REVIEW OF REFEREE RECOMMENDATION
MCR 3.991