Personal Protection Order Page 4
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4Personal Protection Order
PROOF OF SERVICE
Case No.
TO PROCESS SERVER: You must serve the personal protection order 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
AFFIDAVIT OF PROCESS SERVER
Being first duly sworn, I state that I am a legally competent
I certify that I am a sheriff, deputy sheriff, bailiff, appointed
adult who is not a party or an officer of a corporate party, and
court officer, or attorney for a party [MCR 2.104(A)(2)], and
that:
that:
(notarization required)
(notarization not required)
I served a copy of the personal protection order by:
personal service
registered mail, delivery restricted to the respondent (return receipt attached)
on:
Name of respondent
Complete address of service
Day, date, time
Law enforcement agency
Complete address of service
Day, date, time
I have personally attempted to serve a copy of the personal protection order 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.
Name (type or print)
Service fee
Miles traveled Fee
$
$
Signature
Incorrect address fee Miles traveled Fee
TOTAL FEE
$
$
$
Title
Subscribed and sworn to before me on
,
County, Michigan.
Date
My commission expires:
Signature:
Deputy court clerk/Notary public
Date
Notary public, State of Michigan, County of
ACKNOWLEDGMENT OF SERVICE
I acknowledge that I have received a copy of the personal protection order on
.
Day, date, time
Signature of respondent
MCR 2.105(A)
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