Approved, SCAO

STATE OF MICHIGAN

JUDICIAL CIRCUIT
COUNTY

Court  address

Petitioner's name

Address and telephone no. where court can reach petitioner

PROOF OF SERVICE/ORAL NOTICE
REGARDING
PERSONAL PROTECTION  ORDER

Original - Court file
Copies as needed

CASE NO.

Court  telephone  no.

Respondent's name, address, and telephone no.

v

AFFIDAVIT OF SERVICE

I certify that on                                 I personally served

Date

Respondent name

at

Address or location of service

with a copy of the personal protection order issued on

by the

Date

Circuit Court.

Officer signature

Name (type or print)

Law enforcement agency

ID no.

Address

City, state, zip

Telephone no.

Subscribed and sworn to before me on

,

County, Michigan.

Date

My commission expires:

Date

Signature:

Deputy court clerk/Notary public

Notary public, State of Michigan, County of

PROOF OF ORAL NOTICE

I certify that on                                 I orally notified

Date

Respondent name

the existence of a personal protection order issued on

by the

Date

Circuit Court.  I also certify that the respondent was advised of the following:
• the specific conduct enjoined.
• the penalties for violating the order.
• where the respondent could obtain a copy of the personal protection order.

Date

   of

ID no.

Officer signature

Name (type or print)

Law enforcement agency

Address

City, state, zip

CC 386   (3/11)  PROOF OF SERVICE/ORAL NOTICE REGARDING PERSONAL PROTECTION ORDER

MCL 600.2950(22), MCL 600.2950a(19), MCR 3.706(E)

Telephone no.