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Here is the text we could read:

B 1. The petitioner and respondent:

reside or resided in the same household.

have a child in common.

have or had a dating relationship.

C 2.

D 3.

The respondent is between 10 and 17 years of age, is unemancipated, and is not the minor child of the petitioner.

The petitioner is less than 18 years of age, is unemancipated, and is not the minor child of the respondent.

E 4. a. There

Case number

are

other pending actions in this or any other court regarding the parties.

are not
Name of court, county, and state or province

Name of judge

b. There

Case number

are

are not
Name of court, county, and state or province

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

F 5. I need a personal protection order because: Explain what has happened. Attach separate sheet(s).

G 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:
appearing at my workplace or residence.
contacting me by telephone.

following me or appearing within my sight.
sending mail or other communications to me.
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.

Petitioner’s name

Age

Respondent’s name, address, and telephone no.

Age

Address and telephone no. where court can reach petitioner

STATE OF MICHIGANJUDICIAL CIRCUITCOUNTYPETITION FOR PERSONAL PROTECTION ORDER AGAINST A MINOR (DOMESTIC RELATIONSHIP)CASE NO. and JUDGECourt addressCourt telephone no. Approved, SCAOForm CC 375M, Rev. 1/21MCL 600.2950, MCL 600.2950a, MCL 712A.2h, MCR 3.703Page 1 of 2Distribute form to: CourtJudge/Assignment clerkRespondentPetitionerReturn 6. (continued)

respondent.

f. interfering with efforts to remove my children/personal property from premises solely owned/leased by the

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. intentionally causing me mental distress or exerting control over me by:

injuring, killing, torturing, or neglecting, or threatening to injure, kill, torture, or neglect any animal in which

removing any animal from my possession in which I have an ownership interest.
retaining or obtaining possession of any animal in which I have an ownership interest.

I have an ownership interest.

k. purchasing or possessing a firearm.

l. other:

H 7. I make this petition under 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.

Petition for Personal Protection Order Against a Minor (Domestic Relationship)
Page 2 of 2

(1/21)

Case No.

Date

Petitioner’s/Next friend’s signature

Petition for Personal Protection Order Against a Minor (Domestic Relationship)

(1/21)

Case No.

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.

PROOF OF SERVICE

CERTIFICATE / AFFIDAVIT OF SERVICE / NONSERVICE

I served

personally

by registered or certified mail (copy of return receipt attached)

a copy of the petition for personal protection order against a minor, and the attachments listed below on:

I have attempted to serve the personal protection order against a minor, together with the attachments listed below,

and have been unable to complete service on:

Respondent’s name

Date and time of service

Place or address of service

Attachments (if any)

I declare under the penalties of perjury that this proof of service has been examined by me and that its contents are true to
the best of my information, knowledge, and belief.

Service fee
$

Signature

Miles traveled

Fee
$

Incorrect address fee
$

Miles traveled

Fee
$

TOTAL FEE
$

Name (type or print)

Title (if applicable)

Note: If documents are served by someone other than a sheriff, deputy sheriff, or other person listed in MCL 600.1910(b), this return must be notarized.

Subscribed and sworn to before me on

Date

My commission expires on

Notary public, State of Michigan, County of

Deputy clerk/Notary public signature

Name (type or print)

Acting in the County of

This notarial act was performed using an electronic notarization system or a remote electronic notarization platform.

ACKNOWLEDGMENT OF SERVICE

I acknowledge that I have received a copy of the petition for personal protection order against a minor, together with

Attachments

Signature of respondent

Date and time

Signature of respondent’s parent/guardian/custodian

MCR 2.105(A)

CC 375m, Petition for Personal Protection Order Against a Minor (Domestic Relationship)

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the Michigan state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from www.courts.michigan.gov/PPO (2023-03)
Page(s): 3
Fields(s): 87
Average fields per page: 29
Reading Level: Grade 12
LIST Grouping(s): Unknown

Use our Rate My PDF tool to learn more. Go beyond the above insights and learn more about this or any pdf form at RateMyPDF.com, includes: counts of difficult words used, passive voice decetion, and suggestions for how to make the form more usable.

Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

Here are the fields we could identify.

stat_e_f_n_l_county was STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY (0.59 conf)
petitioners_name was Petitioners name (0.46 conf)
age__1 was Age (0.36 conf)
age__2 was Age_2 (0.40 conf)
address_court_petitioner was Address and telephone no where court can reach petitioner (0.48 conf)
child_common was have a child in common (0.40 conf)
dating_relationship was have or had a dating relationship (0.46 conf)
reside_resided_household was reside or resided in the same household (0.40 conf)
respondent_child_petitioner was The respondent is between 10 and 17 years of age is unemancipated and is not the minor child of the petitioner (0.40 conf)
petitioner_minor_respondent was The petitioner is less than 18 years of age is unemancipated and is not the minor child of the respondent (0.39 conf)
are was are (0.38 conf)
are_not was are not (0.41 conf)
docket_number was Case number (1.00 conf)
name_court_county_state__1 was Name of court county and state or province (0.45 conf)
name_judge__1 was Name of judge (0.48 conf)
are_2 was are_2 (0.37 conf)
are_not_2 was are not_2 (0.39 conf)
case_number was Case number_2 (0.40 conf)
name_court_county_state__2 was Name of court county and state or province_2 (0.46 conf)
name_judge__2 was Name of judge_2 (0.44 conf)
entering_either_guardian was a entering onto the property where I live I state that either I or my parent guardian or custodian have a (0.46 conf)
b_entering_onto_property was b entering onto the property at (0.35 conf)
attacking_beating_wounding was c assaulting attacking beating molesting or wounding (0.34 conf)
removing_minor_except was d removing the minor children from the petitioner who has legal custody except as allowed by a custody or (0.41 conf)
e_defined_l_includes_limited was e stalking as defined under MCL 750411h and MCL 750411i which includes but is not limited to (0.45 conf)
undefined__1 was undefined (0.38 conf)
undefined__2 was undefined_2 (0.39 conf)
following_within_sight was following me or appearing within my sight (0.41 conf)
sending_mail_communications was sending mail or other communications to me (0.39 conf)
approaching_public_private was approaching or confronting me in a public place or on private property (0.40 conf)
owned_leased_occupied was entering onto or remaining on property owned leased or occupied by me (0.49 conf)
placing_owned_leased was placing an object on or delivering an object to property owned leased or occupied by me (0.41 conf)
appearing_workplace_residence was appearing at my workplace or residence (0.38 conf)
contacting_telephone was contacting me by telephone (0.48 conf)
text__1 was Text1 (0.35 conf)
judge was Judge (0.39 conf)
text__2 was Text3 (0.35 conf)
text__3 was Text4 (0.35 conf)
text__4 was Text5 (0.35 conf)
text__5 was Text6 (0.35 conf)
f_interfering_efforts_remove_childrenpersonal_property_premises_solely_ownedleased was f interfering with efforts to remove my childrenpersonal property from premises solely ownedleased by the (0.42 conf)
g_threatening_kill_physically_injure was g threatening to kill or physically injure (0.43 conf)
interfering_conduct_impairs was h interfering with me at my place of employment or education or engaging in conduct that impairs my (0.43 conf)
concerning_child_mine was i having access to information in records concerning a minor child of mine and the respondent that will reveal (0.40 conf)
intentionally_causing_exerting was j intentionally causing me mental distress or exerting control over me by (0.45 conf)
purchasing_possessing_firearm was k purchasing or possessing a firearm (0.44 conf)
l was l other (0.44 conf)
undefined__3 was undefined_3 (0.39 conf)
injuring_killing_injure was injuring killing torturing or neglecting or threatening to injure kill torture or neglect any animal in which (0.44 conf)
removing_ownership_interest was removing any animal from my possession in which I have an ownership interest (0.42 conf)
obtaining_ownership_interest was retaining or obtaining possession of any animal in which I have an ownership interest (0.37 conf)
undefined__4 was undefined_4 (0.39 conf)
j was J (0.41 conf)
irreparable_injury_damage_occur was I request an ex parte order because immediate and irreparable injury loss or damage will occur between now (0.43 conf)
text__6 was Text7 (0.35 conf)
checkbox was checkbox100 (0.35 conf)
served was I served (0.36 conf)
personally was personally (0.35 conf)
registered_return_receipt was by registered or certified mail copy of return receipt attached (0.47 conf)
attempted_serve_together was I have attempted to serve the personal protection order against a minor together with the attachments listed below (0.36 conf)
respondents_name was Respondents name (0.33 conf)
date_time_service was Date and time of service (0.37 conf)
place_address_service was Place or address of service (0.34 conf)
attachments__1 was Attachments if any (0.41 conf)
service_fee was Service fee (0.45 conf)
name_type_print__1 was Name type or print (0.45 conf)
tota_l_fee was TOTAL FEE (0.46 conf)
title_applicable was Title if applicable (0.37 conf)
signature_date was Date (1.00 conf)
undefined__5 was undefined_5 (0.39 conf)
name_type_print__2 was Name type or print_2 (0.40 conf)
undefined__6 was undefined_6 (0.39 conf)
acting_county was Acting in the County of (0.37 conf)
undefined__7 was undefined_7 (0.39 conf)
notarial_act_performed_using_electronic_notarization_system_remote_platform was This notarial act was performed using an electronic notarization system or a remote electronic notarization platform (0.44 conf)
attachments__2 was Attachments (0.43 conf)
date_time was Date and time (0.34 conf)
text__7 was Text2 (0.35 conf)
text__8 was Text8 (0.35 conf)
text__9 was Text9 (0.35 conf)
text__10 was Text10 (0.35 conf)
text__11 was Text11 (0.35 conf)
text__12 was Text12 (0.35 conf)
text__13 was Text13 (0.35 conf)
text__14 was Text14 (0.35 conf)
text__15 was Text15 (0.35 conf)
text__16 was Text16 (0.35 conf)

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The Legal Innovation & Technology Lab's Form Explorer Beta @ Suffolk Law School Last updated 2023-04-02

CC 375m, Petition for Personal Protection Order Against a Minor (Domestic Relationship)

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Identified Data Fields:

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The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02