STATE OF MICHIGAN

JUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY

ORDER TO TAKE CHILD(REN) INTO
PROTECTIVE CUSTODY AND PLACE
(CHILD PROTECTIVE PROCEEDINGS)
  EX PARTE

CASE NO.

PETITION NO.

JUDGE

Court address

Court telephone no.

In the matter of 

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

1. Date of entry of order: 
 

 

  Judge/Referee: 

 

THE COURT FINDS:
2. 
 
 
 
 
 
 
 

 a. The child(ren) has/have already been removed from the parent(s), guardian, or legal custodian and is/are absent 
  without leave from court-ordered placement.
 b. Under MCL 712A.2(b), MCR 3.963(B), or MCR 3.974(C)(1), there is reasonable cause to believe that:
  1) The child(ren) is/are at substantial risk of harm or is/are in surroundings that present an imminent risk of harm 
  and the child(ren)'s immediate removal from those surroundings is necessary to protect the child(ren)'s health 
 
  and safety.
 
  2) The circumstances warrant issuing this order.
  3) Continuing to reside in the home is contrary to the child(ren)'s welfare because: (Specify.)

 
 
 
 
 

  4) No remedy other than protective custody is reasonably available to protect the child(ren).
  5) Consistent with the circumstances, reasonable efforts were made to prevent or eliminate the need for removal 
 

  of the child(ren) as follows: (Specify.)

 3. a. Reasonable efforts are not required to prevent or eliminate the child(ren)'s removal from the home due to the 
 
 
 

 father        subjecting the child(ren) to the aggravated circumstance(s) of

 as provided in section MCL 722.638(1) and (2), and as evidenced

(See note below.)
 mother 

 
 
 

 

 .  

 mother's 
 mother's 
 mother's 

 
 
 

 father's     conviction for murder of another child of the parent.
 father's      conviction for voluntary manslaughter of another child of the parent.
 father's      conviction for aiding or abetting in the murder or manslaughter of another child of the

  parent, attempting to murder the child(ren) or another child of the parent, or conspiring or soliciting to commit the 
  murder of the child(ren) or another child of the parent.

 father's      conviction for felony assault that resulted in serious bodily injury to the child(ren) or 

 father's      involuntary termination of parental rights to a sibling of the child(ren) and failure by that

  parent to rectify the conditions that led to that termination.

 mother 

 father       being required to register under the Sex Offender Registration Act.

 mother's 

 
  another child of the parent.
 

 mother's 

Approved, SCAO
Form JC 05b, Rev. 12/22
MCL 712A.2(b), MCL 712A.14a, MCL 712A.19a(2),
MCR 3.963, MCR 3.974(C), MCR 3.976(B)(1), MCR 3.979(F)(2)
Page 1 of 3

 
 
 

 
 
 

 

 

 
 
 
 
 
 
 
 
 
 
 
 

 
 
 

 

 

 
 
 
 
 
 
 
 
 
 
 
 

  by  
 

 

 

 

 

 

 
 
 
 
 
 
 
 
 
 

JIS Code: OTCOrder to Take Child(ren) into Protective Custody and Place (Child Protective Proceedings) 
Page 2 of 3

(12/22) 

Case No. 
 

 not required because the parent subjected the child or another child of the parent to one of the circumstances 

  b. Reasonable efforts to preserve and reunify the family to make it possible for the child(ren) to safely return home are 
 
 
 
 

  stated above.
   OR

 still recommended because: 

 
 
 
 

  NOTE: When item 3 is checked, schedule a permanency planning hearing within 28 days of this determination.
 4. The child(ren) is/are Indian as defined in MCR 3.002(12), subject to the exclusive jurisdiction of a tribal court but 
 
temporarily located off the reservation, and removal of the child(ren) is necessary to prevent imminent physical 
  damage or harm to the child(ren).

IT IS ORDERED:  

TO: 

Specify whether child protective services worker, an officer, or other person deemed suitable by the court under MCR 3.963(B)(1).

5. The child(ren) shall be taken into protective custody and

 a. placed with/returned to the Michigan Department of Health and Human Services for care and supervision.

        Note: If a local MDHHS contact is unknown, you may contact Central Intake at 855-444-3911.

 for medical observation and

 b. placed at 

 

        treatment until medically released to 
 

        for placement at 
 

  Placement shall continue until resumption of the next scheduled hearing.

6. To effect this order you are authorized to enter the premises located at 
 

 
 
 
 
 

 

 
 

 
 

 

 

 

 

 

 7. The parent(s), guardian, or legal custodian of the child(ren) shall be directed to appear for a hearing in this matter to 

 

    be held on 

Date and time (if known)

 at 

Location

    (Item 7 is not applicable for orders to take children into custody who are absent without leave from court-ordered placement.)

 
8. This authorization to enter the premises and take the child(ren) into protective custody expires 
 

 Enter on LEIN

 

 .

 .

 .

 .

                     

 
Note: Referee recommendation not required if acting under MCL 712A.14a(3).

Referee signature and date

Recommended by:

 

                     

Judge/Referee signature and date

Note: To parent(s), guardian, or legal custodian: If you require accommodations to use the court because of a disability or if you require a foreign language 
interpreter to help you fully participate in court proceedings, please contact the court immediately to make arrangements.

Use Note: A referee may issue an interim placement order pending a preliminary hearing.
Reference Note: The term “department” refers to the Michigan Department of Health and Human Services.

Order to Take Child(ren) into Protective Custody and Place (Child Protective Proceedings) 
Page 3 of 3

(12/22) 

Case No. 
 

IDENTIFYING INFORMATION

Race

Sex

Height

Weight

Hair color

Eye color

Date of birth

Race

Sex

Height

Weight

Hair color

Eye color

Date of birth

Race

Sex

Height

Weight

Hair color

Eye color

Date of birth

Race

Sex

Height

Weight

Hair color

Eye color

Date of birth

Home address                                                                                                      City                                   State         Zip               Telephone number

Father’s name                                                                    Address                     City                                   State         Zip                Telephone number

Mother’s name                                                                   Address                     City                                   State          Zip               Telephone number

Pickup radius                                                                                                                          Court ORI      

  Statewide 

  Other:                                                                                                       MI                

Reason for removal is stated in item 2 on page 1 of the order to take child(ren) into protective custody.

CUSTODY STATEMENT AND RECORD OF NOTIFICATION

1. I certify and return that I have taken 

Child(ren)’s name(s)

into custody on 

Date and time

to 

Place of temporary placement

 and have delivered the child(ren)

 .

2. I 

 notified 

 attempted to notify the parent(s), guardian, or legal custodian listed below that the child(ren) has/have

  been taken into protective custody and that a preliminary hearing or an emergency removal hearing will be held on

Date and time

 at 

Location

 .

NAME

METHODS USED
(reasons for failure to notify must be noted)

DATE

TIME

Guardian/Legal custodian

Name

Name

Name

Name

 

 

 

Father

Mother

Other

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

 

Date

 
 

                     
                     

Signature

Agency name