Plaintiff

of 
 

I certify that:

The 

 

 State   

 Township   

 City   

 Village

v

Defendant’s name, address, and telephone no.

 Statute 

 

 Ordinance 

 

Infraction: 
 

 

Infraction date: 
 

DEFAULT ENTRY

1. The defendant has not made a scheduled appearance nor answered the citation within the time allowed by statute.

 2. The defendant is not in the military service or is in the military service but received notice and adequate time and  
    opportunity to appear and defend.

 

 

3. The default of the defendant is entered. 
 

                     

Clerk/Deputy clerk/Magistrate signature and date

THE COURT FINDS:

JUDGMENT

 1. The defendant is responsible and admitted responsibility
   

 in person/by representation.

 by mail. 

 

 

 2. The defendant is in default. The citation/complaint is sufficient to make a determination of responsibility.

 3. After hearing, the defendant 

 

 is 

 

 is not 

 

responsible as amended: 
 

 .

 4. The plaintiff failed to appear.

 5. The plaintiff moved to dismiss the case.

STATE OF MICHIGANJUDICIAL DISTRICTCOUNTYJUDGMENTCivil InfractionCASE NO. and JUDGECourt address                     Court telephone no.     Approved, SCAOForm CIA 02, Rev. 8/21MCR 4.101(B), 50 USC 3931Page 1 of 2Distribute form to: Court Defendant ReturnJudgment, Civil Infraction 
Page 2 of 2

(8/21) 

Case No. 
 

IT IS ORDERED: 
Note: For a defendant on active military duty, default judgment shall not be entered, except as provided by the Servicemembers Civil Relief Act.

 6. The defendant must pay the balance due by returning a copy of this judgment with payment.
    Amount of judgment
$ 
    Fine            
 
$ 
    Costs           
 
$ 
    State costs  
 
$ 
                       
 
    Total            
$ 
 
    Bond forfeited   $ 
 
    Balance due    $ 
 
    Date owed: 
 

 
 
 
 
 
 
 
 
 

 7. Other:

 8. The case is dismissed.

 

                     

Judge/Magistrate/Deputy clerk signature and date

NOTICE TO THE DEFENDANT: Fine, costs, and fees not paid within 56 days of the date owed are subject to a 20% late 
penalty on the amount owed. If you are not able to pay due to financial hardship, contact the court immediately to 
request a payment alternative. 

If this judgment is the result of an informal hearing, you may appeal the decision within 7 days of the judgment date (form 
CIA 05). If this judgment is the result of a formal hearing, you may appeal the decision within 21 days of the judgment date 
(form CIA 05). If this judgment is based on an admission of responsibility, you may file a written request to withdraw your 
admission within 14 days of the admission (form CIA 05). If this judgment is the result of a default, you may be able to have 
the default judgment set aside by filing a motion (form CIA 04) within 14 days of the date the judgment was served. A bond 
equal to the amount of the judgment is required in all instances.

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

CERTIFICATE OF SERVICE

I certify that on this date

  defined by MCR 2.107(C)(3).

 I have personally served a copy of this judgment on the defendant.
 I have served a copy of this judgment on the defendant by first-class mail addressed to his/her last-known address as   

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

 

                     

Clerk/Deputy clerk/Magistrate signature and date