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STATE OF MICHIGAN

JUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY

PETITION
(CHILD PROTECTIVE PROCEEDINGS)
Supplemental

Amended

Court address

CASE NO.

PETITION NO.

JUDGE

1. In the matter of (State the name, county of legal residence, race, sex, and date and place of birth of each child, and indicate with whom the child lives.)

ORI
MI-

a. Name of child and county of legal residence

Sex

DOB

Place of birth

Race

b. Name of child and county of legal residence

Race Sex

DOB

Place of birth

c. Name of child and county of legal residence

Race Sex

DOB

Place of birth

d. Name of child and county of legal residence

Race Sex

DOB

Place of birth

e. Name of child and county of legal residence

Race Sex

DOB

Place of birth

f. Name of child and county of legal residence

Race Sex

DOB

Place of birth

g. Name of child and county of legal residence

Race Sex

DOB

Place of birth

h. Name of child and county of legal residence

Race Sex

DOB

Place of birth

Court telephone no.

Living with:
Mother

Father
Other

2. The names and addresses and other relevant information of the parents, guardian, legal custodian, or nearest known
relative are as follows: If the father/mother/guardian or legal custodian is a respondent, place a check mark in the column R. Name each
father’s children and indicate for which child the father is a legal father by placing (LF) after the name of each child. If there is no (LF) designation,
the father is presumed to be the putative father of the named child. For example: John Doe (LF), Mary Doe (LF).

a. Father’s name

DOB

Address

Telephone no.

b. Father’s name

DOB

Address

Telephone no.

c. Father’s name

DOB

Address

Telephone no.

d. Father’s name

DOB

Address

Telephone no.

Name(s) of child(ren)

e. Mother’s name

f. Mother’s name

DOB

Address

DOB

Address

g. Nonparent adult respondent’s name

DOB

Address

h. Guardian/Legal custodian’s name

DOB

Address

Approved, SCAO
Form JC 04b, Rev. 3/23
MCL 712A.2, MCR 3.903(A), MCR 3.926(A), MCR 3.961
Page 1 of 3

Telephone no.

JIS Code: PETPetition (Child Protective Proceedings)
Page 2 of 3

(3/23)

Case No.

a. There are no pending or resolved cases within the jurisdiction of the family division of the circuit court involving the

family or family members of the person(s) who are the subject of the petition.

b. There is one or more pending or resolved cases within the jurisdiction of the family division of the circuit court
involving the family or family members of the person(s) who are the subject of the petition. I have separately filed
a completed confidential case inventory (form MC 21) listing those cases.

c. It is unknown if there are pending or resolved cases within the jurisdiction of the family division of the circuit court

involving the family or family members of the person(s) who are the subject of the complaint.

(See page 3 for specific allegations.)

child(ren) pursuant to MCL 700.5205.

Removal is requested below and attached are details

parent, guardian, nonparent adult, or other custodian, is an unfit place for the child(ren) to live.

The parent has substantially failed, without good cause, to comply with a court-structured plan for the child(ren)

The home or environment, by reason of neglect, cruelty, drunkenness, criminality, or depravity on the part of the

The parent has substantially failed, without good cause, to comply with a limited guardianship placement plan for the

is a/are member(s) of or eligible for membership in the
Indian tribe.

describing the active efforts made to provide remedial services and rehabilitative programs designed to prevent the
breakup of the Indian family and documentation and attempts to identify the child’s tribe.

A military/nonmilitary affidavit is attached.
The parent or other person legally responsible for the care and maintenance of the child(ren), when able to do so,
neglected or refused to provide proper or necessary support, education, medical, surgical, or other care necessary
for the child(ren)’s health or morals, or he/she has subjected the child(ren) to a substantial risk of harm to his or her
mental well-being, or he/she has abandoned the child(ren) without proper custody or guardianship.

4. The named child(ren) come within the provisions of MCL 712A.2(b)(1)-(6) as follows (check all that apply):

person.

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.

The child(ren) has/have a guardian pursuant to the estates and protected individuals code and the parent meets
both of the following criteria: (i) the parent, having the ability to support or assist in supporting the child(ren), has failed
or neglected, without good cause, to provide regular and substantial support for two years or more before the filing of
the petition or, if a support order has been entered, has failed to substantially comply with the order for two years
or more before the filing of the petition, and (ii) the parent, having the ability to visit, contact, or communicate with the
child(ren), has regularly and substantially failed or neglected, without good cause, to do so for two years or more
before the filing of the petition.

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 responsible

the juvenile is alleged to have committed a commercial sexual activity as that term is defined in MCL 750.462a or

pursuant to MCL 700.5207 and 700.5209.

5. The reason(s) why it is contrary to the welfare of the child(ren) for the child(ren) to remain in the home are: (Attach
separate sheets as needed.)

6. The reasonable effort(s) made to prevent the removal of the child(ren) include: (Attach separate sheets as needed.)

Judge/Referee signature and date

8. I request the court to

a. refer the matter to alternative services.
b. authorize this petition and take jurisdiction over the child(ren). Further, I request the court to

issue an order removing

the child(ren)
c. terminate parental rights of father to child(ren)
d. terminate parental rights of mother to child(ren)

1.a.
1.a.

the abuser
1.b.
1.b.

1.c.
1.c.

from the home.
1.d.
1.d.

1.e.
1.e.

1.f.
1.f.

1.g.
1.g.

1.h.
1.h.

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

Petitioner’s signature Date

Agency/Address

City, state, and zip Telephone no.

Print or type name

Approved by:

Prosecutor’s signature (optional) and date

is authorized.
is not authorized.

Note: Use form JC 11a to authorize the petition following a preliminary hearing.

9. A preliminary inquiry has been conducted and the filing of this petition
on
on

the following child(ren)
the following child(ren)

the child(ren)
the child(ren)

Petition (Child Protective Proceedings)
Page 3 of 3

(3/23)

Case No.

7. The specific allegations are: (Attach separate sheets as needed.)

JC 04b, Petition (Child Protective Proceedings)

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/juvenile-proceedings (2023-03)
Page(s): 3
Fields(s): 178
Average fields per page: 59
Reading Level: Grade 11
LIST Grouping(s): FA-00-00-00-00.

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.

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

JC 04b, Petition (Child Protective Proceedings)

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