Form CC 376

PERSONAL PROTECTION ORDER
(DOMESTIC RELATIONSHIP)

Use this form if you filled out form CC 375, Petition for Personal Protection Order.

INSTRUCTIONS FOR COMPLETING "PERSONAL PROTECTION ORDER"

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

Items A through D must be completed before you give this form to the court clerk. Please read the instructions for 
each item. Then fill in the correct information for that item on the form.

A     If you checked box  G  on form CC 375, check the box "Ex Parte."

    telephone number to be kept from the respondent, do not write your address here. Put in the address 
    of a relative or friend or a post office box where the court can contact you.

B     Fill in the “Case No.” from form CC 375.
 
C     Fill in the “petitioner” information the same way you did on form CC 375. If you want your address and 
 
 
 
D     Write in the respondent’s information and as much of the other information 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.

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 judge 
who signed 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 Personal Protection Order. This form is available from the circuit court clerk.

STATE OF MICHIGAN

JUDICIAL CIRCUIT
COUNTY

PERSONAL PROTECTION ORDER
 EX PARTE
(DOMESTIC RELATIONSHIP)

CASE NO.

Petitioner’s name

Respondent’s name, address, telephone no., and driver’s license no.

Address and telephone no. where court can reach petitioner

D

v

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.																				**Needed	for	NCIC	entry

Date: 
 

   Judge: 

1. This order is entered 

 without a hearing. 

 **after hearing.

THE COURT FINDS:

 2. A petition requested respondent be prohibited from entry onto the premises, and either the parties are married, petitioner 
    has a property interest in the premises, or respondent does not have a property interest in the premises.

 3. 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 notice itself will precipitate adverse action before the order can be issued.

 4. Respondent poses a credible threat to the physical safety of petitioner and/or a child of petitioner.

 5. Respondent 
    residing or had resided in the same household as petitioner. 

 

 **is the spouse or former spouse of petitioner, had a child in common with petitioner, or is

 

 has or had a dating relationship with petitioner.

IT IS ORDERED:

6.  

Name

  a. entering onto property where petitioner lives.

  b. entering onto property at 
  

** 

  c. assaulting, attacking, beating, molesting, or wounding 

Name

  d. removing minor children from petitioner who has legal custody, except as allowed by custody or parenting-time order 

    provided removal of the children does not violate other conditions of this order.  An existing custody order is dated

 .  An existing parenting-time order is dated 

 

  e. stalking as defined under MCL 750.411h and MCL 750.411i that includes but is not limited to:

 following petitioner or appearing within his/her sight. 
 sending mail or other communications to petitioner. 
 approaching or confronting petitioner in a public place or on private property.
 entering onto or remaining on property owned, leased, or occupied by petitioner.
 placing an object on or delivering an object to property owned, leased, or occupied by petitioner.

  
  

 appearing at petitioner’s workplace or residence.
 contacting petitioner by telephone.

(SEE OTHER PAGE)

 Bar no.

 .

 .

 .

 is prohibited from:

C

D

** 
 

 

 

 

 

 

 
 

 

   

  

   
   
   
   
   

** 
 
 
 
 
 

   

Approved, SCAOCourt telephone no.Court addressORIMI-ABCC 376 (6/17) PERSONAL PROTECTION ORDER (Domestic Relationship)MCL 600.2950, MCR 3.705, MCR 3.706, 18 USC 922(g)(8)(c)3rd copy - Petitioner (pink)4th copy - Return (yellow)5th copy - Return (goldenrod)Original - Court1st copy - Law enforcement agency (file) (green)2nd copy - Respondent (blue)Personal Protection Order
 

(6/17) Page 
 

  

 of 

  

Case No. 
 

interfering with petitioner’s efforts to remove his/her children/personal property from premises solely owned/leased by

 

g. threatening to kill or physically injure 

 

Name

 .

 

h. interfering with petitioner at his/her place of employment or education or engaging in conduct that impairs his/her

 

        employment or educational relationship or environment.

 

i. having access to information in records concerning a minor child of petitioner and  respondent that will reveal petitioner's
 
 

        address, telephone number, or employment address or that will reveal the child's address or telephone number.

intentionally causing petitioner mental distress or exerting control over petitioner by:

injuring, killing, torturing, or neglecting, or threatening to injure, kill, torture, or neglect any animal in which petitioner 

removing any animal from his/her possession in which petitioner has an ownership interest.
retaining or obtaining possession of any animal in which petitioner has an ownership interest.

 

j.
 
 
 
       
            has an ownership interest.
       
       

 
 

 **

 

k. purchasing or possessing a firearm.
 

 

 
IT IS ORDERED:
 6. (continued)
f.
 
 
 
 

        respondent.

 

 **
 
 
 

 
 

 
 
 
 
 

 

 

 

l. other: 
 
 
 

       

 

       

 

 

 7. As a result of this order, federal and/or state law may prohibit you from possessing or purchasing ammunition or a firearm.

 8. Violation of this order subjects respondent to immediate arrest and to the civil and criminal contempt powers of the court. If 
 

found guilty, respondent shall be imprisoned for not more than 93 days and may be fined not more than $500.00.

This order is effective when signed, enforceable immediately, and remains in effect until 
 

 9.
 .
  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 respondent violates this order in 
  a jurisdiction other than this state, respondent is subject to enforcement and penalties of the state, Indian tribe, or United 
  States territory under whose jurisdiction the violation occurred.

 10.

The court clerk shall file this order with 

 who will enter it into the LEIN.

Name of law enforcement agency

 11. Respondent may file a motion to modify or terminate this order. For ex parte orders, the motion must be filed within 14 
 

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

 

 

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

Date and time issued

 

Judge 

 

 

 

Bar no.

MCR 2.105(A)

PROOF OF SERVICE

Case No.

Personal Protection Order

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

  AFFIDAVIT OF PROCESS SERVER

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)

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.

Name of respondent

Complete address of service

Subscribed and sworn to before me on 

 County, Michigan.

 declare that the statements above are true to the best of my information, knowledge, and belief.

Miles traveled Fee

Signature

Miles traveled Fee

TOTAL FEE

Name (type or print)

$

$

Title

 , 
 

$

Date

 

ACKNOWLEDGMENT OF SERVICE

My commission expires: 

Date

 Signature 

Deputy court clerk/Notary public

Notary public, State of Michigan, County of 

                     

 
Service fee

$
 
                     
Incorrect address fee
 
                     
$

  I

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

 .

Day, date, time

Signature of respondent