THE PEOPLE OF

 The State of Michigan

 
 

In the matter of 

First and last name(s)

Probationer’s name, address, and telephone no.

v

CTN/TCN

SID

1. Payment of restitution was ordered as a condition of probation for the individual named above. Upon review of the  
  case as required under statute, I have determined that the probationer has not paid restitution as ordered.

 

2. The amount of the arrearage was $ 

 

3. The reasons for this arrearage are:

 as of 

Date

 .

Date

Date

 

 

Probation officer/Juvenile caseworker

CERTIFICATE OF MAILING

Use note: does not need to be completed if the 
document is served through MiFILE.

I served a copy of this report on the probationer and the prosecuting attorney by first-class mail addressed to their last-
known addresses as defined by MCR 2.107(C)(3). I declare under the penalties of perjury that this certificate of mailing has 
been examined by me and that its contents are true to the best of my information, knowledge, and belief.

Signature  

 

 

STATE OF MICHIGANJUDICIAL DISTRICTJUDICIAL CIRCUITCOUNTYREPORT OFNONPAYMENT OF RESTITUTIONCASE NO. and JUDGECourt addressCourt telephone no.Approved, SCAOForm MC 258, Rev. 9/20MCL 712A.30(18), MCL 769.1a(15), MCL 780.766(18), MCL 780.794(18), MCL 780.826(15)Page 1 of 1Distribute form to: CourtProbationerProbation officerProsecuting attorney

MC 258, Report of Nonpayment of Restitution

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About This Form:

• Sourced from www.courts.michigan.gov/probation (2023-03)
• Page(s): 1
• Fields(s): 21
• Average fields per page: 21
• Reading Level: Grade 10
• LIST Grouping(s): CR-00-00-00-00.

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