Approved, SCAO

STATE OF MICHIGAN

JUDICIAL CIRCUIT
COUNTY

Court  address
ORI
MI-
A

Petitioner's name

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

PERSONAL PROTECTION ORDER
(NONDOMESTIC SEXUAL ASSAULT)
EX PARTE

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

CASE NO.

Court  telephone  no.

Respondent's name, address, telephone no., and DLN

Address and telephone no. where court can reach petitioner

v

B

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.

Date:

Judge:

no hearing.

after hearing.

1. A petition has been filed requesting an order under MCL 600.2950a(2).
2. The petitioner requested an ex parte order, which should be entered without notice because irreparable injury, loss, or
damage will result from the delay required to give notice or the notice itself will precipitate adverse action before the order
can be issued.
The respondent has been convicted of sexual assault against the petitioner as follows:
The petitioner is a minor and the respondent has been convicted of furnishing obscene material to the petitioner in violation
of MCL 750.142 or a substantially similar law from another jurisdiction as follows:
The petitioner has a reasonable apprehension of sexual assault because the respondent has sexually assaulted the
petitioner or threatened the petitioner with sexual assault.
The petitioner is a minor and the respondent has furnished obscene material to the petitioner.

3.

4.

 is prohibited from

       .

entering onto property where the petitioner lives.
entering onto property at
threatening to sexually assault, kill, or physically injure the petitioner or a named individual.
purchasing or possessing a firearm.
interfering with the petitioner's efforts to remove the petitioner's children or personal property from premises that are solely
owned or leased by the respondent.
interfering with the petitioner at the petitioner's place of employment or education, or engaging in conduct that impairs
the petitioner's employment or educational relationship or environment.
following the petitioner or appearing within the petitioner's sight.
approaching or confronting the petitioner in a public place or on private property.
appearing at the petitioner's workplace or residence.
entering onto or remaining on property owned, leased, or occupied by the petitioner.
contacting the petitioner by telephone.
sending mail or electronic communications to the petitioner.
placing an object on or delivering an object to property owned, leased, or occupied by the petitioner.
posting an electronic message with the intent to cause others to contact the petitioner in a way that would make the
petitioner feel terrorized, frightened, intimidated, threatened, harassed, or molested.
any other specific act or conduct that imposes upon or interferes with the petitioner's personal liberty or that causes a
reasonable apprehension of violence or sexual assault, as follows:

5. Violation of this order subjects the respondent to immediate arrest and to the civil and criminal contempt powers of the court.
If found guilty, the respondent shall be imprisoned for not more than 93 days and may be fined not more than $500.00.

6. 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 the respondent violates this order
in a jurisdiction other than this state, the respondent is subject to enforcement and penalties of the state, Indian tribe, or United
States territory under whose jurisdiction the violation occurred.

7. The court clerk shall file this order with
8. For an ex parte order, the respondent may file a motion to modify or terminate the order within 14 days after being served

                                                     ,who will enter it into the LEIN.

with or receiving actual notice of the order. Forms and instructions are available from the clerk of the court.

9. A motion to extend the order must be filed 3 days before the expiration date in item 6 or a new petition must be filed.

Date and time issued

Judge

CC 396   (3/12)   PERSONAL PROTECTION ORDER (NONDOMESTIC SEXUAL ASSAULT)

Bar no.
MCL 600.2950a, MCR 3.705, MCR 3.706,
18 USC 922(g)(8)(c)

PROOF OF SERVICE

Personal Protection Order
(Nondomestic Sexual Assault)
Case No.

TO PROCESS SERVER:  You must serve the personal protection order 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 by:

personal service

registered mail, delivery restricted to the respondent (return receipt attached)

on:
Name of respondent

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 on the following respondent and have been unable
to complete service.

Respondent 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
$

Name (type or print)

Signature

Title

     ,

Subscribed and sworn to before me on

Date

  County, Michigan.

My commission expires:

      Signature:

Date

Deputy court clerk/Notary public

Notary public, State of Michigan, County of

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

    .

Day, date, time

ACKNOWLEDGMENT OF SERVICE

Signature of respondent

MCR 2.105(A)

Form CC 396

PERSONAL PROTECTION ORDER
(NONDOMESTIC SEXUAL ASSAULT)

Use this form if you filled out form CC 395, Petition for Personal Protection Order (Nondomestic Sexual
Assault).

INSTRUCTIONS FOR COMPLETING "PERSONAL PROTECTION ORDER
(NONDOMESTIC SEXUAL ASSAULT)"

Please print neatly.  Press firmly because you are printing on six copies.

Items A and B 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 395.  If you want the address
and telephone number where you live to be kept from the respondent, do not write that 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 about the respondent as you know. This
information will help the police to 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).

The court will complete the rest of this form.

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

•

•

Important:

If the respondent violates this personal protection order and is arrested, the court will set a date, time, and place for
a hearing on the charges against the respondent to be held within 72 hours after arrest.  The court or prosecutor is
responsible for giving you notice of this hearing.  If you are not notified within 24 hours of the arrest, contact the court
that issued this order.  If a hearing is not held within 72 hours, the respondent may be released from jail after posting
bond pending the hearing.

If the respondent violates this personal protection order and there is no arrest, use form CC 382, Motion and Order to
Show Cause for Violating Valid Personal/Foreign Protection Order.  This form is available from the circuit court clerk.