STATE OF MICHIGAN

JUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY

ORDER OF ADJUDICATION
(CHILD PROTECTIVE PROCEEDINGS)

ORDER 
 

 OF 
 

CASE NO.

PETITION NO.

JUDGE

Court address

Court telephone no.

In the matter of 

First and last name(s), alias(es)

1. Date of hearing: 

 2. Removal date: 

 

 

THE COURT FINDS:

 

  Judge/Referee: 

 

 (Specify for each child if different.)

3. A petition has been submitted alleging that the above child(ren) come(s) within the provisions of MCL 712A.2(b).

4. The child(ren) 

 is/are 

 is not/are not  subject to the continuing jurisdiction of another court. 

5. 

 Notice of hearing was given as required by law. 

 Notice of proceedings is to be given as required by law.

 a. Based on testimony, there is probable cause to believe the legal/putative father(s) is/are:

        (Name each child, his/her father, and whether legal or putative.)

 b. The putative father of 
 c.  The putative father was notified as required by law and failed to establish paternity within the time set by the court.
        The putative father waives all rights to further notice, including the right to notice of termination of parental rights 
        and the right to an attorney.

 is unknown and cannot be identified. 

 

7. The respondent(s) 

Name(s)

 did not appear 

 appeared in court in person or by 

Manner of appearance

  and 

 was/were represented by an attorney. 

 waived representation by an attorney.

 8. The plea by 

Name(s)

 

    is knowingly, understandingly, and voluntarily made.

Use Note: Use of this form is optional when the court conducts the dispositional hearing immediately following adjudication.
Reference Note: The term “department” refers to the Michigan Department of Health and Human Services.

Approved, SCAO
Form JC 49, Rev. 12/22
MCL 712A.2, MCL 712A.13a, MCL 712A.14, MCL 712A.19a(2), 
MCL 712A.19b(4), MCL 722.638, MCR 3.002, MCR 3.205(A), MCR 3.921(B),
MCR 3.972, MCR 3.976(B)(1)
Page 1 of 5

 

 

 

Court: 
 

   

 
 
 
 

 

 

6. 
 

 

PCS Code: OCPTCS Code: ADH/OFAHOrder of Adjudication (Child Protective Proceedings) 
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Case No. 
 

 a preponderance of the evidence, 

 

 clear and convincing evidence,

9. By  
 
 
 
 

      after 
         
 
 
 
         

 

 

 

 trial of 
 

 admission of plea by 

 

, 

 

 

 

 

 

 no contest plea by 

 failure to provide, when able to do so, support, education, medical, surgical, or other necessary care for health 

, 
 a. there are no statutory grounds to exercise jurisdiction over the child(ren).
 b. there are statutory grounds to exercise jurisdiction over the child(ren) (MCL 712A.2[b]). The statutory ground(s) 

 substantial risk of harm to mental well-being.
 abandonment by parents, guardian, or other custodian.
 lack of proper custody or guardianship.
 an unfit home or environment, by reason of neglect, cruelty, drunkenness, criminality, or depravity on the part 

 
 
          is/are:
         
              or morals.
         
         
         
         
              of  a parent, guardian, nonparent adult, or other custodian.
 failure to comply with a limited guardianship placement plan.
         
 failure to comply with a court-structured guardianship plan.
         
         
 when a guardianship is in place, failure to provide support or to regularly visit, contact or communicate with the
              child(ren) for a period of 2 years, either before or after a guardianship petition was filed and a support order entered.
         
             
             
                  responsible person.
             
 the juvenile is alleged to have committed a commercial sexual activity as that term is defined in 
                  MCL 750.462a or a delinquent act that is the result of force, fraud, coercion, or manipulation exercised by a 
                  parent or other adult.
 the juvenile’s custodial parent or legally responsible person has died or has become permanently 
             
                  incapacitated and no appropriate parent or legally responsible person is willing and able to provide care for 
                  the juvenile.

              
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
10.  Specific findings of facts and law are 
 

 the juvenile is in danger of substantial physical or psychological harm and is dependent because
 the juvenile is homeless or not domiciled with a parent or other legally responsible person.
 the juvenile has repeatedly run away from home and is beyond the control of a parent or other legally 

 b.  Consistent with the circumstances, reasonable efforts were made to prevent or eliminate removal of the 

 a. Contrary to the welfare findings were made in a prior order.
 b. It is contrary to the welfare of the child(ren) to remain in the home because: (Attach separate sheets as necessary.)

 a. Consistent with the circumstances, reasonable efforts to prevent or eliminate removal of the child(ren) from the
 

   
 11. 
     
              
 12. 
              home were made as determined in a prior order. 
     
              child(ren) from the home. Those efforts include: (Specify below.) 
     
              qualified expert witness who has knowledge about the child-rearing practices of the Indian child’s tribe, 
              that active efforts 
              rehabilitative programs designed to prevent the breakup of the Indian family. These efforts have proved 
             
             
             
  be removed from the home. (Specify below.)
      The efforts for 12.b or 12.c are: (Specify the efforts from 12.b or 12.c here. If the child is an Indian child, specify active efforts as defined 
      by MCR 3.002[1] and MCL 712B.3[a].)

 
 successful,  the continued custody of the child(ren) by the parent or Indian custodian 
likely to result in serious emotional or physical damage to the child(ren), and the child(ren)

 c.  The child(ren) is/are Indian, and the court finds by clear and convincing evidence and the testimony of a 

 have not  been made to provide remedial services and

 unsuccessful, 
 is not 
 
 is 
 
 should 

 in the attached written opinion. 

 as noted below.

 on the record. 

 should not 

 
 
 
 
 
 
 
 
 
 
 
 

 have 

OR

OR

   

 
 

 

 

 

 

 

 

 

 

     
     
              determined in a prior order.  

 d. Reasonable efforts to prevent or eliminate removal of the child(ren) from the home were not made.
 e. Reasonable efforts to prevent or eliminate removal of the child(ren) from the home were not required as 

 
 
 
Note: If the child(ren) were not removed before adjudication and the court determines at trial that removal is necessary, the 
court must make the required findings regarding contrary to the welfare and reasonable efforts to prevent removal. 

 
 

 

 

 
 
 
 
 
 
 
 
 
 

 
 
 
 
 
 

 

Order of Adjudication (Child Protective Proceedings) 
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Case No. 
 

 13.  a. Reasonable efforts are not required to prevent or eliminate the child(ren)’s removal from the home due to the
         
             

subjecting the child(ren) to the aggravated circumstance(s) of

 as provided in section MCL 722.638(1) and (2), and as evidenced

 mother 

 father 

 

 

              by  
 

             

 

 

 .

 

 father’s 
 father’s 
 father’s 

 mother’s 
 mother’s 
 mother’s 

conviction for murder of another child of the parent.
conviction for voluntary manslaughter of another child of the parent.
conviction for aiding or abetting in the murder or manslaughter of 

         
         
         
              another child of the parent, attempting to murder the child(ren) or another child of the parent, or conspiring or 
              soliciting to commit the murder of the child(ren) or another child of the parent.
         
              child(ren) or another child of the parent.
         
              and failure by that parent to rectify the conditions that led to that termination.
         

conviction for felony assault that resulted in serious bodily injury to the

involuntary termination of parental rights to a sibling of the child(ren) 

being required to register under the Sex Offender Registration Act. 

 mother’s 

 mother’s 

 father’s 

 father’s 

 mother  

 father 

      b. Reasonable efforts to preserve and reunify the family to make it possible for the child(ren) to safely return home are 
         
 not required because the parent subjected the child or another child of the parent to one of the circumstances 
              stated above. 
              OR
         
  
 

 still recommended because: 

 

  (When item 13 is checked, either complete item 15 below or schedule a permanency planning hearing within 28 days of this determination.) 

 
 
 

      
 
      

safely return home.

child(ren)’s health and safety. 

 a. Reasonable efforts shall be made to preserve and reunify the family to make it possible for the child(ren) to 

 b. Reasonable efforts shall not be made to preserve and reunify the family because it would be detrimental to the

 14. 
 
  
 
 15. Because reasonable efforts to prevent or eliminate removal or to reunite the child(ren) and family are not required, a
  permanency planning hearing was conducted. (Use and attach form JC 19, Order Following Dispositional Review/Permanency 
 
  Planning Hearing.)  
 

 
 
16.  Custody of the child(ren) with the parent/guardian/legal custodian
 
 
 
 
 
 
 

 
         
              adequately safeguard the child(ren) from the risk of harm to the child(ren)’s life, physical health, or mental 
              well-being.
         
              is/are placed are adequate to safeguard the child(ren)’s health and welfare.
 

 Conditions of custody at the placement away from the home and with the individual with whom the child(ren) 

 b. does not present a substantial risk of harm to the child(ren)’s life, physical health, or mental well-being.

 No provision of service or other arrangement except removal of the child(ren) is reasonably available to 

 a.  presents a substantial risk of harm to the child(ren)’s life, physical health, or mental well-being.

 17. 
     

 

 a. All siblings are in joint placement.
 b. All siblings are not in joint placement because:

 

              Sibling contact 

 is occurring according to law. 

 is not occurring because (see item 24 to order sibling contact):

 18. Parenting time with 

 

 , even if supervised, may be harmful to the child(ren).

Order of Adjudication (Child Protective Proceedings) 
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Case No. 
 

IT IS ORDERED: 

 

 ,

 The father was not present and must 

  appear at the next hearing. 
  14 days.

 a. is/are placed with the department for care and supervision, and

 The putative father was present at this hearing and shall establish paternity within 

  and the jurisdiction of this court is terminated except that the court reserves the right to enforce orders for 
  reimbursement of court costs, attorney fees, and other assessments that have accrued up to and including the date 
  of this order.

 19. The petition is dismissed, the child(ren) is/are released to 
 
 
 
 20. Notice is to be given to the legal/putative father(s) as required by law. 
 
 
 21.  The child(ren) 
      
               1) the parent(s), guardian, or legal custodian shall execute all documents necessary to release confidential
                  information regarding the child(ren), including medical, mental, and educational reports, and shall also, 
                  within 7 days, provide the department with the name(s) and address(es) of the medical provider(s) for the 
                  child(ren). Any medical provider of the child(ren) shall release the medical records of the child(ren) to the 
                  department.
              2) if the child(ren) is/are placed in the home of a relative, a home study shall be performed by the department 
                  and a copy of the home study submitted to the court not more than 30 days after the placement.
               3) upon request, the department shall release to the foster parent the information concerning the child(ren) in
                  accordance with MCL 712A.13a(18).
             
                  is authorized to enter the premises located at 
 
                  This authorization to enter the premises and take the child(ren) into protective custody expires 
 
                 
      

 The child(ren) shall be taken into protective custody. To effect this order,  
 

 under the supervision of 

 b.  is/are released to 

 Enter on LEIN

 . 
 .

Name(s) of parent(s), guardian, or legal custodian

 The following terms and conditions apply to the parent(s), guardian, or legal custodian:

              the department. 
   
   

 22. While the child(ren) is/are placed out of the home, the friend of the court must take the necessary steps to appropriately 
 

assign or redirect child support pursuant to law.

 23.  The child(ren) named 
      shall have 
      parenting time.
 24.  Sibling contact shall be as follows:

 

 

 a psychological evaluation 

 

 counseling  

 

to determine appropriateness and conditions of 

 a. Parenting time of 
 unsupervised. 
 The department has discretion to allow unsupervised or supervised parenting time by its designee.

 supervised until further order of the court.

 

 b.  Parenting time of  
 
 unsupervised. 
 The department has discretion to allow unsupervised or supervised parenting time by its designee.

 supervised until further order of the court.

 c.  Parenting time of 
 unsupervised. 
 The department has discretion to allow unsupervised or supervised parenting time by its designee.

 supervised until further order of the court.

 

 is 

 is

 is 

 25. 
             
             
   
     
             
             

     
             
             
 d. 
     

 
 
 

 
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 

 

 
 

 
 
 
 
 
 

 
 
 
 

Order of Adjudication (Child Protective Proceedings) 
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Case No. 
 

IT IS ORDERED:  (continued)

 27.  Other:

 26.  Placement shall continue pending disposition on 

Date and time

 .

 28.  Prior orders remain in effect except as modified by this order.

Recommended by: Referee signature and date

MCL 722.638 - AGGRAVATED CIRCUMSTANCES

Judge signature and date

if one or more of the following apply:
(a) The department determines that a parent, guardian, or legal custodian, or a person who is 18 years of age or older and who resides 
    for any length of time in the child’s home, has abused the child or a sibling of the child and the abuse included one or more of the 
    following:
    (i)   Abandonment of a young child.
    (ii)  Criminal sexual conduct involving penetration, attempted penetration, or assault with intent to penetrate.
    (iii) Battering, torture, or other serious physical harm.
    (iv) Loss or serious impairment of an organ or limb.
    (v)  Life threatening injury.
    (vi) Murder or attempted murder.
(b) The department determines that there is risk of harm, child abuse, or child neglect to the child and either of the following is true:
    (i)  The parent’s rights to another child were terminated as a result of proceedings under Section 2(b) of Chapter XIIA of 
        1939 PA 288, MCL 712A.2, or a similar law of another state and the parent has failed to rectify the conditions that led to the prior 
        termination of parental rights.
    (ii) The parent’s rights to another child were voluntarily terminated following the initiation of proceedings under Section 2(b) of 
        Chapter XIIA of 1939 PA 288, MCL 712A.2, or a similar law of another state, the parent has failed to rectify the conditions that
        led to the prior termination of parental rights, and the proceeding involved abuse that included 1 or more of the following:
        (A) Abandonment of a young child.
        (B) Criminal sexual conduct involving penetration, attempted penetration, or assault with intent to penetrate.
        (C) Battering, torture, or other serious physical harm.
        (D) Loss or serious impairment of an organ or limb.
        (E) Life-threatening injury.
        (F) Murder or attempted murder.
        (G) Voluntary manslaughter.
        (H) Aiding and abetting, attempting to commit, conspiring to commit, or soliciting murder or voluntary manslaughter.

(1)  The department shall submit a petition for authorization by the court under Section 2(b) of Chapter XIIA of 1939 PA 288, MCL 712A.2, 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
(2)  In a petition submitted as required by subsection (1), if a parent is a suspected perpetrator or is suspected of placing the child at an
unreasonable risk of harm due to the parent’s failure to take reasonable steps to intervene to eliminate that risk, the department shall
 
include a request for termination of parental rights at the initial dispositional hearing as authorized under Section 19b of Chapter XIIA 
 
of 1939 PA 288, MCL 712A.19b.
 
(3)  If the department is considering petitioning for termination of parental rights at the initial dispositional hearing as authorized under 
section 19b of chapter XIIA of 1939 PA 288, MCL 712A.19b, even though the facts of the child’s case do not require departmental 
 
action under subsection (1), the department shall hold a conference among the appropriate agency personnel to agree upon the 
 
course of action. The department shall notify the attorney representing the child of the time and place of the conference, and the 
 
attorney may attend. If an agreement is not reached at this conference, the department director or the director’s designee shall resolve 
 
the disagreement after consulting the attorneys representing both the department and the child.