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STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY
Court address

PETITION FOR PERSONAL PROTECTION ORDER AGAINST A MINOR (DOMESTIC RELATIONSHIP), PAGE 1

CASE NO.

Court telephone no.

A

Petitioner name Address and telephone no. where court can reach petitioner

DOB

Respondent name, address, and telephone no.

DOB or age

v

B C D E

1. The petitioner and respondent: have a child in common. have or had a dating relationship. reside or resided in the same household. 2. The respondent is between 10 and 17 years of age, is unemancipated, and is not the minor child of the petitioner. 3. The petitioner is less than 18 years of age, is unemancipated, and is not the minor child of the respondent. 4. a. There are are not other pending actions in this or any other court regarding the parties.
Case number Name of court and county Name of judge

b. There
Case number

are

are not

orders/judgments entered by this or any other court regarding the parties.
Name of judge

Name of court and county

F G

5. I need a personal protection order because: Explain what has happened (attach additional sheets).

H I J

6. I ask the court to grant a personal protection order prohibiting the respondent from: a. entering onto the property where I live. I state that either I or my parent, guardian, or custodian have a property interest in the premises, I am married to the respondent, or the respondent or his/her parent, guardian, or custodian has no property interest in the premises. b. entering onto the property at . c. assaulting, attacking, beating, molesting, or wounding . d. removing the minor children from the petitioner who has legal custody, except as allowed by a custody or parenting time order as long as removal of the children does not violate other conditions of the personal protection order. e. stalking as defined under MCL 750.411h and MCL 750.411i, which includes but is not limited to: following me or appearing within my sight. appearing at my workplace or residence. sending mail or other communications to me. contacting me by telephone. approaching or confronting me in a public place or on private property. entering onto or remaining on property owned, leased, or occupied by me. placing an object on or delivering an object to property owned, leased, or occupied by me. f. interfering with efforts to remove my children/personal property from premises solely owned/leased by the respondent. g. threatening to kill or physically injure . h. interfering with me at my place of employment or education or engaging in conduct that impairs my employment or educational relationship or environment. i. having access to information in records concerning a minor child of mine and the respondent that will reveal my address, telephone number, or employment address or that will reveal the child's address or telephone number. j. purchasing or possessing a firearm. k. other: 7. I make this petition under the authority of MCL 600.2950/600.2950a/712A.2h and ask the court to grant a personal protection order. I request an ex parte order because immediate and irreparable injury, loss, or damage will occur between now and a hearing or because notice itself will cause irreparable injury, loss, or damage before the order can be entered. 8. I have a next friend petitioning for me. I certify that the next friend is not disqualified by statute and is an adult.

Date CC 375M (3/09)

Petitioner's signature MCL 600.2950, MCL 600.2950a, MCL 712A.2h, MCR 3.703

PETITION FOR PERSONAL PROTECTION ORDER AGAINST A MINOR (Domestic Relationship), Page 1

Petition for Personal Protection Order Against a Minor Case No. PROOF OF SERVICE TO PROCESS SERVER: You must serve the copies of the petition for 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 petition for personal protection order against a minor by: personal service 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

I have personally attempted to serve a copy of the petition for personal protection order against a minor on the following respondent and have been unable to complete service.
Respondent name Complete address of service

I declare that the statements above are true to the best of my information, knowledge, and belief.
Service fee Miles traveled Fee Signature TOTAL FEE Name (type or print) Title

$ $

$ $ $

Incorrect address fee Miles traveled Fee

Subscribed and sworn to before me on
Date

, Signature:
Deputy court clerk/Notary public

County, Michigan.

My commission expires:
Date

Notary public, State of Michigan, County of

ACKNOWLEDGMENT OF SERVICE I acknowledge that I have received a copy of the petition for personal protection order against a minor on
Day, date, time Signature of respondent's parent/guardian/custodian

.

Signature of respondent Signature of respondent's parent/guardian/custodian MCR 2.105(A)

Form CC 375M PETITION FOR PERSONAL PROTECTION ORDER AGAINST A MINOR (DOMESTIC RELATIONSHIP)
Use this form if the person you want restrained is less than 18 but at least 10 years of age and: 1) if you live with or have lived with the person you want restrained and that person is not your unemancipated minor child; or 2) if you and the person you want restrained have a child in common even if you were never married to one another or never lived together; or 3) if you and the person you want restrained have or had a dating relationship.

INSTRUCTIONS FOR COMPLETING "PETITION FOR PERSONAL PROTECTION ORDER AGAINST A MINOR" Please print neatly. Press firmly because you are printing on five copies. By filling in this form, you are asking for a personal protection order that tells the minor respondent not to do certain things you don't want him or her to do. If you are in immediate danger, you should ask the judge for an "ex parte" order, which can be issued without waiting for a hearing. Items A through J must be completed before your petition can be filed with the court. Please read the instruction for each item. Then fill in the correct information for that item on the form. A Write your name, address, and telephone number in the "Petitioner" box. If you are under 18 years of age, write in your date of birth. Write the name, address, telephone number, and date of birth or age of the person you want restrained in the "Respondent" box. If you want your address and telephone number to be kept from the other party, do not write your address here. Put in the address of a relative or friend or a post office box where the court can contact you.

B - D Check the boxes that best describe your relationship with the respondent. E Check whether there is a pending case between you and the respondent. Examples of a case are: support, paternity, child support, other personal protection actions, etc. If there is a pending case, fill in the case number, the name of the court and county where the action was filed, and the name of the judge. Check whether there are any court orders or judgments between you and the respondent. Examples of orders are parenting time (visitation) orders, custody orders, other personal protection orders, etc. If there are other court orders or judgments, fill in the case number, the name of the court and county where the order or judgment was entered, and the name of the judge that signed the order. F Explain in as much detail as possible why you are asking for a personal protection order. Describe what has happened or what has been threatened so the judge has enough facts to decide if a personal protection order should be signed. Include dates and places. Write on a separate sheet of paper and attach it to this form. Check only those boxes you need because you must be able to convince the judge you need all the protection you are requesting. On the lines after each item you check, fill in the requested information such as names, addresses, or specific types of activity you do not want allowed. Check item "6.b." only if you want to keep the other party from entering onto property other than your home (for example, school, work, etc.). Check item "e." only if there have been two or more acts of harassment. If you want the court to order that any records that exist which contain information about yourself or your minor children be kept confidential, state that in box "k." Examples of such records are school reports which the respondent would normally have access to. An "ex parte order" means you do not have to let the respondent know in advance that you are asking the court for an order and you do not have to wait for a court hearing to get the order. Check the box for an "ex parte order" if you believe the other party might hurt you or threaten you if he or she found out you were getting a personal protection order. If you do not need to check the "ex parte" box, you must have a court hearing. Fill out form CC 381. I If you are under 18 years old, you may need an adult (called a "next friend") to petition for you. Check this box if you have a next friend helping you file this form. Write in today's date and sign the form. Hand the form to the county clerk. The clerk will fill in the rest of the information and will give you your copies.

G

H

J

NOTE: There are only five copies of this form. You will need to make extra copies of this form for each parent, guardian, or custodian of the respondent. You must read the booklet "Instructions for Personal Protection Orders" for directions on the legal process.