1. The petitioner and the respondent have never been husband and wife, resided in the same household together, 
      had a child in common, or had a dating relationship with one another. The respondent is not the unemancipated  
 
      minor child of the petitioner. The petitioner is not the unemancipated minor child of the respondent. The respondent 
      is between 10 and 17 years of age.

B   2. 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 

 

 are 

 are not 

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

Case number

Name of court, county, and state or province

Name of judge

C   3. I need a personal protection order because
 
 

     
              me  (insert case number in item 2a.).

 a. the minor respondent is subject to an order of disposition or other adjudication based on sexual assault against 

 
 
 

 
 

 b. I am a minor and the minor respondent is subject to an order of disposition or other adjudication based on 

     
              furnishing obscene material to me in violation of MCL 750.142 or a substantially similar law from another 
              jurisdiction (insert case number in item 2a.).

 c.  I have a reasonable apprehension of sexual assault because the minor respondent has sexually assaulted me 

     
              or  threatened me with sexual assault. Explain what has happened (attach additional sheets).

 
 

     
              additional sheets).

 d. I am a minor and the minor respondent has furnished obscene material to me. Explain what has happened (attach  

 

STATE OF MICHIGANJUDICIAL CIRCUITCOUNTYPETITION FOR PERSONAL PROTECTION ORDER AGAINST A MINOR (NONDOMESTIC SEXUAL ASSAULT)CASE NO. and JUDGECourt addressCourt telephone no.Approved, SCAOForm CC 395M, Rev. 1/21MCL 600.2950a, MCR 3.703Page 1 of 2Distribute form to: Court Judge/Assignment clerkRespondentPetitionerReturnAPetitioner’s nameAgevRespondent’s name, address, and telephone no.AgeAddress and telephone no. where court can reach petitionerPetition for Personal Protection Order Against a Minor (Nondomestic Sexual Assault) 
Page 2 of 2

(1/21) 

Case No. 
 

D   4. I make this petition under the authority of MCL 600.2950a(2) and ask the court to grant a personal protection order
 
 

      prohibiting the minor respondent from
 entering onto property where I live.
     

     

 threatening to sexually assault, kill, or physically injure me or another named person 

 

     

 entering onto property at 
 

         

 

     

 purchasing or possessing a firearm.

 .

 .

 interfering with my efforts to remove my children or personal property from premises that are solely owned or 

     
          leased by the minor respondent.

 interfering with me at my place of employment or education, or engaging in conduct that impairs my employment 

     
          or  educational relationship or environment.

     

 following me or appearing within my sight.

     

 approaching or confronting me in a public place or on private property.

     

 appearing at my workplace or residence.

     

 entering onto or remaining on property owned, leased, or occupied by me.

     

 contacting me by telephone.

     

 sending mail or electronic communications to me.

     

 placing an object on or delivering an object to property owned, leased, or occupied by me.

 posting an electronic message with the intent to cause others to contact me in a way that would make me feel 

     
          terrorized, frightened, intimidated, threatened, harassed, or molested.

 doing any other specific act or conduct that imposes upon or interferes with my personal liberty or that causes me 

     
          a reasonable apprehension of violence or sexual assault, as follows: 

 5. 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.

 6. 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

 

 

 

   

   

 

   

 

   

   

   

   

 

   

   

 
 

   

 

 

 

         

         

 

 

E  
 
 

F  

G  
 
 

Date

Petition for Personal Protection Order Against a Minor (Nondomestic Sexual Assault) 

(1/21) 

Case No. 
 

PROOF OF SERVICE

TO PROCESS SERVER: You must serve the copies of the petition for personal protection order against a minor 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

 I served 

 

 personally 

 

 by registered or certified mail (copy of return receipt attached)

  a copy of the petition for personal protection order against a minor, and the attachments listed below on: 

 I have attempted to serve the petition for personal protection order against a minor, together with the attachments listed 

  below, and have been unable to complete service on:

Respondent’s name

Place or address of service

Day, date and time of service

Name of parent/guardian/custodian

Place or address of service

Day, date and time of service

Name of parent/guardian/custodian

Place or address of service

Day, date and time of service

Attachments (if any)

                     

I declare under the penalties of perjury that this proof of service has been examined by me and that its contents are true to 
the best of my information, knowledge, and belief.
 
Service fee
$
                     
 
Incorrect address fee
$
 

  
Name (type or print)

TOTAL FEE
$

  
Signature

                     

Miles traveled

Miles traveled

Fee
$

Fee
$

 

 

 

 

 

 

  
Title (if applicable)

Note: If documents are served by someone other than a sheriff, deputy sheriff, or other person listed in MCL 600.1910(b), this return must be notarized.

Subscribed and sworn to before me on 
 
 

                     
                     

Date

My commission expires on 
 
Notary public, State of Michigan, County of 

                     

 

 

 

 

 

 

 

 

 

 

Deputy clerk/Notary public signature

 . 

Name (type or print)
 

 

 . 

 Acting in the County of 

 

 This notarial act was performed using an electronic notarization system or a remote electronic notarization platform.

I acknowledge that I have received of a copy of the petition for personal protection order against a minor, together with

ACKNOWLEDGMENT OF SERVICE

 . 
 

 .

 . 

 on 

 Date and time

Signature of respondent

ttachments

  A

Signature of respondent’s parent/guardian/custodian

Signature of respondent’s parent/guardian/custodian

    

MCR 2.105(A)