Approved, SCAO

STATE OF MICHIGAN

JUDICIAL DISTRICT

JUDICIAL CIRCUIT

COUNTY PROBATE

ORDER OF
DISQUALIFICATION/REASSIGNMENT

CASE NO.

Court  address

Court  telephone  no.

Plaintiff name(s) and address(es)

Defendant name(s) and address(es)

v

Plaintiff's attorney, bar no., address, and telephone no.

Defendant's attorney, bar no., address, and telephone no.

In the matter of

IT IS ORDERED:

impropriety.

years.

9. Other:  (specify)

I, Hon.
                                                                                                                  on my own motion,
am disqualified under MCR 2.003 from hearing this case and I am requesting assignment of another judge for the following reason:

,        on motion of

Bar no.

 ,

1. I am biased or prejudiced for or against a party or attorney.

2. I have, based on objective and reasonable perceptions, a serious risk of actual bias impacting the due process rights of a

party as enunciated in Caperton v Massey, 556 US 868; 129 S Ct 2252; 173 L Ed 2d 1208 (2009).

3. I believe, based on objective and reasonable perceptions, my continued assignment would create an appearance of

4. I have personal knowledge of disputed evidentiary facts concerning the proceeding.

5. I have been consulted or employed as an attorney in the matter in controversy.

6. I was a partner of a party, attorney for a party, or a member of a law firm representing a party within the preceding two

7. I know that I, individually or as a fiduciary, or my spouse, parent, or child wherever residing, or any other member of my

family residing in my household, have more than a de minimis economic interest in the subject matter in controversy that
could be substantially impacted by the proceeding.

8. I or my spouse, or a person within the third degree of relationship to either of us, or the spouse of such a person:  (i) is a party
to the proceeding, or an officer, director, or trustee of a party; (ii) is acting as a lawyer in the proceeding; (iii) is known by
me to have a more than de minimis interest that could be substantially affected by the proceeding; or (iv) is to my knowledge
likely to be a material witness in the proceeding.

Date

Judge

Bar no.

MC 264   (3/12)   ORDER OF DISQUALIFICATION/REASSIGNMENT

MCR 2.003, MCR 8.111(C)

ADDITIONAL DISQUALIFICATIONS

NOTE:  If there are not enough signature slots, attach additional sheets.

The undersigned judge(s) is/are also disqualified and refer by number to the reason printed on the front of this form.
NOTE:  IF REASON 9 IS ENTERED, THE COMMENT SECTION MUST BE COMPLETED.

REASON
1-9

DATE

SIGNATURE

COMMENT

REQUEST FOR REFERRAL TO SCAO

All of the judges of this court have disqualified themselves and have signed this order, indicating their reason for disqualification
pursuant to MCR 2.003.

The designated Visiting Judge Clerk shall submit a copy of this order, ALONG WITH THE REQUEST FOR ASSIGNMENT, to the
appropriate State Court Administrative Office to have another judge assigned to hear this case pursuant to MCR 2.003(D)(4).

Chief Judge

Bar no.

INTERNAL REASSIGNMENT REQUEST

has been chosen by lot or local administrative order from the judges not

Bar no.

 disqualified in this case. I request that this case be reassigned to this judge.

 Reassignment approved as requested.

Court Administrator or Clerk of the Court

Chief Judge

Bar no.

Date

 Judge

Date

Date