Approved, SCAO

STATE OF MICHIGAN

JUDICIAL CIRCUIT
COUNTY

Original - Court
1st copy - Law enforcement agency (file) (green)
2nd copy - Respondent (blue)

PERSONAL PROTECTION ORDER AGAINST
A MINOR (NONDOMESTIC), PAGE 1
EX PARTE

3rd copy - Petitioner (pink)
4th copy - Return (yellow)
5th copy - Return (goldenrod)

CASE NO.

Court  address
ORI
MI-
A

Petitioner's name

Court  telephone  no.

Respondent's name, address, and telephone no.

Address and telephone no. where court can reach petitioner

v

B

 Full name of respondent (type or print)  *

Driver's license number (if known)

Height

Weight

Race *

Sex * Date of birth or age*  Hair color Eye color

Other identifying information

*These items must be filled in for the police/sheriff to enter on LEIN; the other items are not required but are helpful.

C  Full name of respondent's parent, guardian, custodian (type or print)

Full name of respondent's parent, guardian, custodian (type or print)

 Address and telephone no. if different from above

Address and telephone no. if different from above

Date:

Judge:

1. This order is entered

without a hearing.

after hearing.

THE COURT FINDS:

2. A petition requesting an order to restrain conduct prohibited under MCL 750.411h and MCL 750.411i and/or MCL 750.411s

has been filed under the authority of MCL 600.2950a.

3. The respondent is less than 18 years of age, is unemancipated, and is not the minor child of the petitioner.
4. The petitioner is less than 18 years of age, is unemancipated, and is not the minor child of the respondent.
5. Petitioner requested an ex parte order, which should be entered without notice because irreparable injury, loss, or damage
will result from delay required to give notice or notice itself will precipitate adverse action before an order can be issued.

6. Respondent committed the following acts of willful, unconsented contact:  (State the reasons for issuance.)

IT IS ORDERED:

7.

Name

is  prohibited from

a. stalking as defined under MCL 750.411h and MCL 750.411i, which includes but is not limited to

following or appearing within sight of the petitioner.
appearing at the workplace or the residence of the petitioner.
approaching or confronting the petitioner in a public place or on private property.
entering onto or remaining on property owned, leased, or occupied by the petitioner.
sending mail or other communications to the petitioner.
contacting the petitioner by telephone.
placing an object on or delivering an object to property owned, leased, or occupied by the petitioner.
threatening to kill or physically injure
purchasing or possessing a firearm.
other:

Name

CC 380M   (3/12)   PERSONAL PROTECTION ORDER AGAINST A  MINOR (NONDOMESTIC), Page 1

MCL 600.2950a, MCL 712A.2(h),
 MCR 3.705, MCR 3.706

(PLEASE SEE OTHER SIDE)

Bar no.

   .

Approved, SCAO

STATE OF MICHIGAN

A

JUDICIAL CIRCUIT
COUNTY

PERSONAL PROTECTION ORDER AGAINST
A MINOR (NONDOMESTIC), PAGE 2
EX PARTE

B

CASE NO.

Court  telephone  no.

Respondent's name

v

Court  address
ORI
MI-

Petitioner's name

IT IS FURTHER ORDERED:

7. (continued from page 1)

b. posting a message through the use of any medium of communication, including the Internet or a computer or any electronic

medium, pursuant to MCL 750.411s.

8. a. If the respondent is 17 years of age or more, violation of this order subjects the respondent to immediate arrest and to the

civil and criminal contempt powers of the court. If found guilty of a violation, the respondent shall be imprisoned for not
more than 93 days and may be fined not more than $500.00.

b. If the respondent is less than 17 years of age, violation of this order subjects the respondent to immediate apprehension
or being taken into custody.  If found guilty of a violation, the respondent shall be subject to the dispositional alternatives
listed in MCL 712A.18.

9. 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.

10. The court clerk shall file this order with

who will enter it into the LEIN.

Name of law enforcement agency

   ,

11. The respondent may file a motion to modify or terminate this order.  If this is an ex parte order, a motion to modify or terminate
this order and a request for a hearing must be made within 14 days after the respondent has been served or has received
actual notice of this order.  Forms and instructions are available from the clerk of the court.

12. A motion to extend the order must be filed 3 days before the expiration date in item 9 or a new petition must be filed.

13. Other:

Date and time issued

Judge

CC 380M   (3/12)   PERSONAL PROTECTION ORDER AGAINST A MINOR (NONDOMESTIC), Page 2

PROOF OF SERVICE

      Case No.

Personal Protection Order
Against a Minor (Nondomestic)

TO PROCESS SERVER:  You must serve the 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

OFFICER CERTIFICATE

OR

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 personal protection order against a minor by

personal service on:

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

Law enforcement agency

Complete address of service

Day, date, time

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

Respondent's name

Complete address of service

I declare that the statements above are true to the best of my information, knowledge, and belief.

Miles traveled Fee

Service fee
$
Incorrect address fee Miles traveled Fee
$

$

$

TOTAL FEE
$

Signature

  Name (type or print)

Title

    ,

Subscribed and sworn to before me on

Date

My commission expires:

      Signature:

Date

Deputy court clerk/Notary public

Notary public, State of Michigan, County of

ACKNOWLEDGMENT OF SERVICE

  County, Michigan.

I acknowledge that I have received a copy of the personal protection order against a minor on

                            .

Day, date, time

Signature of respondent

Signature of respondent's parent/guardian/custodian

Signature of respondent's parent/guardian/custodian

MCR 2.105(A)

Form CC 380M

PERSONAL PROTECTION ORDER
AGAINST A MINOR
(NONDOMESTIC)

Use this form if you filled out form CC 377M, Petition for Personal Protection Order Against a Minor.

INSTRUCTIONS FOR COMPLETING "PERSONAL PROTECTION ORDER
AGAINST A MINOR (NONDOMESTIC)"

Please print neatly.

Items A through C must be completed before you give this form to the court clerk.  Please read the instruction for each
item.  Then fill in the correct information for that item on the form.

Fill in the "petitioner" and "respondent" the same way you did on form CC 377M.  If you want your address
and telephone number to be kept from the respondent, 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.

Write in the respondent's name and as much of the other information as you know. This information will help
the police identify the respondent if he or she disobeys the restraining order.  Be sure to identify the respondent
accurately. The race, sex, and date of birth are required for law enforcement to enter an order on the Law
Enforcement Information Network (LEIN).

C

Write in the name(s) and address(es) of the respondent's parent(s), guardian(s), or custodian(s).

The court will complete the rest of this form.

NOTE:  There are only six 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.

If you asked for an ex parte order (order without a hearing), read pages 3 and 4 of the booklet.

If you did not ask for an ex parte order or the judge refuses to sign an ex parte order, read pages 5 and 6
of the booklet.

A

B

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•