In the matter of 

First and last name(s), alias(es)

Name(s) of child(ren) affected by the order being appealed

Name and address of petitioner

Name and phone number of lawyer-guardian ad litem for child(ren)

1. The respondent, 

Name

 , filed a request for the appointment of an

  attorney and a declaration of indigency in order to appeal an order entered on 

 in the 

 Circuit Court, 

 

 

 

  Judge 

IT IS ORDERED:

 

 

 a.  the request is untimely.

 b. the respondent is not indigent.

2. The respondent’s request for appellate counsel is denied because: 

 County, Michigan, by 

Date

 .

 

 

                     

Judge signature and date

Note to Respondent: If your request for appointment of counsel was denied because you are not indigent, you have 
21 days from the date of this order to appeal the order terminating your parental rights. MCR 7.204(A)(1). Form MC 55 can 
be used.

If your request for appellate counsel was untimely or you do not file your claim of appeal within 21 days, you may file an 
application for leave to appeal. In no event shall an application for leave to appeal an order terminating parental rights be 
granted if filed more than 63 days after entry of an order of judgment on the merits, or if filed more than 63 days after entry 
of an order denying reconsideration or rehearing. MCR 3.993(C).

Approved, SCAO
Form JC 85, Rev. 3/21
MCR 3.977, MCR 3.993, MCR 7.204, MCR 7.205
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STATE OF MICHIGANJUDICIAL CIRCUIT - FAMILY DIVISIONCOUNTYORDER DENYING APPOINTMENT OFAPPELLATE COUNSELCASE NO.PETITION NO.JUDGECourt address                     Court telephone no.     JIS Code: ODA