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43rd copy - Petitioner (pink)
Original - Court
4th copy - Return (yellow)
1st copy - Law enforcement agency (file) (green)
Approved, SCAO
5th copy - Return (goldenrod)
2nd copy - Respondent (blue)
STATE OF MICHIGAN
CASE NO.
A
B
PERSONAL PROTECTION ORDER
JUDICIAL CIRCUIT
EX PARTE
COUNTY
(DOMESTIC RELATIONSHIP)
Court address
Court telephone no.
ORI
MI-
C
Petitioner's name
Respondent's name, address, telephone no., and DLN
v
Address and telephone no. where court can reach petitioner
Height
Weight
Race *
Sex * Date of birth or age* Hair color Eye color
Other identifying information
D
**Needed for NCIC entry.
*These items must be filled in for the police/sheriff to enter on LEIN; the other items are not required but are helpful.
Date:
Judge:
no hearing.
**after hearing.
1. A petition requested respondent be prohibited from entry onto the premises, and either the parties are married, petitioner
has property interest in the premises, or respondent does not have a property interest in the premises.
2. Petitioner requested an ex parte order, which should be entered without notice because irreparable injury, loss, or damage
will result from the delay required to give notice or notice itself will precipitate adverse action before the order can be issued.
3. Respondent poses a credible threat to the physical safety of the petitioner and/or a child of the petitioner.
**
4. Respondent
**is the spouse or former spouse of the petitioner, had a child in common with the petitioner, or is residing
or had resided in the same household as the petitioner.
has or had a dating relationship with the petitioner.
IT IS ORDERED:
5.
is prohibited from:
a.entering onto property where petitioner lives.
b.entering onto property at
.
c. assaulting, attacking, beating, molesting, or wounding
.
**
d.removing minor children from petitioner who has legal custody, except as allowed by custody or parenting-time order
provided removal of the children does not violate other conditions of this order. An existing custody order is dated
. An existing parenting-time order is dated
.
e.stalking as defined under MCL 750.411h and MCL 750.411i that includes but is not limited to:
**
following petitioner or appearing within his/her sight.
appearing at petitioner's workplace or residence.
sending mail or other communications to petitioner.
contacting petitioner by telephone.
approaching or confronting petitioner in a public place or on private property.
entering onto or remaining on property owned, leased, or occupied by petitioner.
placing an object on or delivering an object to property owned, leased, or occupied by petitioner.
f. interfering with petitioner's efforts to remove his/her children/personal property from premises solely owned/leased by
respondent.
g. threatening to kill or physically injure
.
**
h. interfering with petitioner at his/her place of employment or education or engaging in conduct that impairs his/her
employment or educational relationship or environment.
i. having access to information in records concerning a minor child of petitioner and respondent that will reveal petitioner's
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:
6. As a result of this order, federal and/or state law may prohibit you from possessing or purchasing ammunition or a firearm.
7. Violation of this order subjects respondent to immediate arrest and to the civil and criminal contempt powers of the court.
If found guilty, respondent shall be imprisoned for not more than 93 days and may be fined not more than $500.00.
8. This order is effective when signed, enforceable immediately, and remains in effect until
.
This order is enforceable anywhere in this state by any law enforcement agency when signed by a judge, and upon service,
may also be enforced by another state, an Indian tribe, or a territory of the United States. If respondent violates this order
in a jurisdiction other than this state, respondent is subject to enforcement and penalties of the state, Indian tribe, or United
States territory under whose jurisdiction the violation occurred.
9. The court clerk shall file this order with
who will enter it into the LEIN.
10. Respondent may file a motion to modify or terminate this order. For ex parte orders, the motion must be filed within 14 days
after being served with or receiving actual notice of the order. Forms and instructions are available from the clerk of court.
11. A motion to extend the order must be filed 3 days before the expiration date in item 8 or a new petition must be filed.
Date and time issued
Judge
Bar no.
PERSONAL PROTECTION ORDER (Domestic Relationship)
MCL 600.2950, MCR 3.705, MCR 3.706,
18 USC 922(g)(8)(c)
CC 376 (3/12)
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