Form CC 377

PETITION FOR
PERSONAL PROTECTION ORDER
(NONDOMESTIC)

Use this form if you want an order to restrain another person over the age of 18 and you do not have a 
domestic relationship to this person.

INSTRUCTIONS FOR COMPLETING "PETITION FOR PERSONAL PROTECTION ORDER (NONDOMESTIC)"

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

 
 
 
 

 
 
 

 
 
 

 

By filling in this form, you are asking for a personal protection order that tells the respondent not to do certain things 
you don't want him or her to do. If you are in immediate danger, you should ask the judge for an "ex parte" order, 
which will be issued without waiting for a hearing.

Items A through H must be completed before your petition can be filed with the court. Please read the instructions 
for each item.  Then fill in the correct information for that item on the form.

A   Write your name, address, and telephone number in the "Petitioner" box. If you are under 18 years of age, write 

in your age. Write the name, address, and telephone number of the person you want restrained in the 
“Respondent” box; if he or she is under 18 years of age, write in his/her age. If you want your address and
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   Check the box if the respondent is required to carry a firearm while at work. If you aren't sure, check the box 
 

"unknown."

 

C   Check whether there is a pending action between you and the respondent. If there is, fill in the case number,
the name of the court, the county, and the state or province where the action was filed, and the name of the
 
judge.
 

 
 

  Check whether there are any court orders or judgments between you and the respondent.  If there are, fill in
 
  entered, and the name of the judge that signed the order.

the case number, the name of the court, the county, and the state or province where the order or judgment was 

D   Explain in as much detail as possible why you are asking for a personal protection order.  Describe what has 
  happened or what has been threatened so the judge has enough facts to decide if a personal protection order 
 
  should be signed. If you want to prohibit stalking, you must detail two or more separate instances of harassment 
 
(unconsented contact) that caused you to feel terrorized, frightened, intimidated, threatened, harassed, or 
 
 
  molested. Include dates and places. Write on a separate sheet of paper and attach it to this form. If you only 
 
  want to prohibit the posting of a message through the use of any medium of communication, including the 
 
 
 
 
 

Internet or a computer or any electronic medium, you must detail what caused you to feel terrorized, frightened, 
intimidated, threatened, harassed, or molested.

E    Check only those boxes you need because you must be able to convince the judge you need all the protection 
  you are requesting. Check box a only if you provided details in item 4 that support an order against stalking.

 

F   An "ex parte order" means you do not have to let the party know in advance that you are asking the court 

 
for an order and you do not have to wait for a court hearing to get the order.  Check the box for an "ex parte 
  order" if you believe the other party might hurt you or threaten you if he or she found out you were getting an
  ex parte personal protection order.

 

If you do not check the box for an ex parte order, you must have a court hearing.  Fill out form CC 381.

G   If you are under 18 years old, you may need an adult (called a "next friend") to petition for you.  Check this box 
 

if you have a next friend helping you file this form, and have the next friend sign the petition.

 

H   Write in today's date and sign the form.  Hand the form to the county clerk.  The clerk will fill in the rest of the 
 

information and will give you your copies.

 

You must read the booklet "Instructions for Personal Protection Orders" for directions on the legal process.

A Petitioner’s name

Age

Respondent’s name, address, and telephone no.

Age

Address and telephone no. where court can reach petitioner

v

1. The petitioner and respondent have never been married, resided in the same household together, had a child in common,  
  or had a dating relationship with one another.
2. 

 The respondent is required to carry a firearm in the course of his/her employment. 

  Unknown.

 

3. a. There 

 

  are 

 

  are not 

  other pending actions in this or any other court regarding the parties. 

 

Case number

Name of court, county, and state or province

Name of judge

 
  b. There 

         
 

 

Case number

  are 

 

  are not 

  orders/judgments entered by this or any other court regarding the parties.

Name of court, county, and state or province

Name of judge

  

4. I need a personal protection order because:  Explain what has happened (attach separate sheets).     

the respondent from

5. I make this petition under the authority of MCL 600.2950a(1) and ask the court to grant a personal protection order prohibiting
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 a.  stalking me as defined by MCL 750.411h and MCL 750.411i, which includes but is not limited to
 
 
 
 
 
 
 
 
 
 
 b. posting a message through the use of any medium of communication, including the Internet or a computer or any 
  electronic medium, pursuant to MCL 750.411s.

 following me or appearing within my sight.
 appearing at my workplace or residence.
 approaching or confronting me in a public place or on private property.
 entering onto or remaining on property owned, leased, or occupied by me.
 sending mail or other communications to me. 
 contacting me by telephone.
 placing an object on or delivering an object to property owned, leased, or occupied by me.
 threatening to kill or physically injure me. 
 purchasing or possessing a firearm.
 other: 
 

 
 
 
 
 
 
 
 
 
 

  

 

F

 

 6. I request an ex parte order because immediate and irreparable injury, loss, or damage will occur between now and a 
  hearing or because notice itself will cause irreparable injury, loss, or damage before the order can be entered.

 7. I have a next friend petitioning for me. I certify that the next friend is not disqualified by statute and is an adult.

 

 

Petitioner’s/Next friend’s signature

 

B C

D

E

G

Date

H

Approved, SCAOCourt telephone no.Court addressCC 377 (6/19) PETITION FOR PERSONAL PROTECTION ORDER (NONDOMESTIC)MCL 600.2950a, MCR 3.703STATE OF MICHIGANJUDICIAL CIRCUITCOUNTYPETITION FORPERSONAL PROTECTION ORDER(NONDOMESTIC)CASE NO.Original - Court1st copy - Judge/Assignment clerk (green)2nd copy - Respondent (blue)3rd copy - Petitioner (pink)4th copy - Return (yellow)MCR 2.105(A)

PROOF OF SERVICE

Case No.

Petition for Personal Protection
Order (Nondomestic)

TO PROCESS SERVER:  You must serve the copies of the petition for 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 petition for personal protection order by:

  registered mail, delivery restricted to the respondent (return receipt attached) 

 

  personal service 
 

on: 
 
 
Respondent name

 

Complete address of service

Day, date, time

 I have personally attempted to serve a copy of the petition for personal protection order on the following respondent and have 

  been unable to complete service.

Respondent name

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.

  I

Miles traveled Fee

Signature

 

 

 

 

 

 
 
Service fee
$
 
 
 
Incorrect address fee
$
 
 
 

 

 

 

 

 

 

 

 

Miles traveled Fee

$

$

TOTAL FEE
$

Name (type or print)

Title

 , 
 

My commission expires: 

Date

 Signature 

Deputy court clerk/Notary public

Notary public, State of Michigan, County of 

Date

 

ACKNOWLEDGMENT OF SERVICE

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

 .

Day, date, time

Signature of respondent