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Form CC 376M
PERSONAL PROTECTION ORDER
AGAINST A MINOR
(DOMESTIC RELATIONSHIP)
Use this form if you filled out Form CC 375M, Petition for Personal Protection Order Against a Minor.
INSTRUCTIONS FOR COMPLETING "PERSONAL PROTECTION ORDER AGAINST A MINOR"
Please print neatly. Press firmly since you are printing on 6 copies.
Items A through E 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 H on Form CC 375M, check the box “Ex Parte.”
B Fill in the “Case No.” from Form CC 375M.
C Fill in the “petitioner” and “respondent” the same way you did on Form CC 375M. 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.
D Write in the respondent’s name 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).
E Write in the name(s) and address(es) of the respondent’s parent(s), guardian(s), or custodian(s).
The court will complete the rest of this form.
NOTE: There are only 6 copies of this form. You will need to make extra copies of this form for each parent,
guardian, or custodian of the respondent.
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.
STATE OF MICHIGAN
JUDICIAL CIRCUIT
COUNTY
PERSONAL PROTECTION ORDER AGAINST
A MINOR (DOMESTIC RELATIONSHIP)
EX PARTE
PAGE 1 OF 2
CASE NO.
Petitioner’s name
Respondent’s name, address, and telephone no.
Address and telephone no. where the court can reach petitioner
v
Full name of respondent (type or print)*
Driver’s license number (if known)
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.
Full name of respondent’s parent, guardian, custodian (type or print)
Full name of respondent’s parent, guardian, custodian (type or print)
Address and telephone no. if different from above
Address and telephone no. if different from above
1. This order is entered
without a hearing.
**after hearing.
Judge:
Bar no.
in the premises, or respondent does not have a property interest in the premises.
2. A petition requested respondent be prohibited from entry onto the premises, and either the petitioner has property interest
3. The respondent is less than 18 years of age, is unemancipated, and is not the minor child of the petitioner.
4. The petitioner is less than 18 years of age, is unemancipated, and is not the minor child of the respondent.
5. The petitioner requested an ex parte order, which should be entered without notice because irreparable injury, loss, or damage
will result from delay required to give notice or notice itself will precipitate adverse action before an order can be issued.
6. The respondent poses a credible threat to the physical safety of the petitioner and/or a child of the petitioner.
**
is residing or had resided in the same household as the petitioner.
has or had a dating relationship with the petitioner.
**is the spouse or former spouse of the petitioner, had a child in common with the petitioner, or
**Needed for NCIC entry
Date:
THE COURT FINDS:
7. The respondent
IT IS ORDERED:
8.
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
(SEE SECOND PAGE)
is prohibited from:
.
.
1
C
D
E
Approved, SCAOCourt telephone no.Court addressORIMI-ABCC 376M (7/16) PERSONAL PROTECTION ORDER AGAINST A MINOR (Domestic Relationship), Page MCL 600.2950, MCL 712A.2(h), MCR 3.705, MCR 3.70618 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) 2
IT IS FURTHER ORDERED:
8. (continued from page 1)
**
**
e. stalking as defined under MCL 750.411h and MCL 750.411i, which includes but is not limited to:
following or appearing within sight of the petitioner.
appearing at workplace/residence of the petitioner.
approaching or confronting the petitioner in a public place or on private property.
entering onto or remaining on property owned, leased, or occupied by the petitioner.
sending mail/other communications to the petitioner.
contacting the petitioner by telephone.
placing an object on or delivering an object to property owned, leased, or occupied by the petitioner.
f. interfering with petitioner’s efforts to remove his/her children or personal property from premises solely owned
or leased by respondent.
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.
j. intentionally causing petitioner mental distress or exerting control over petitioner by:
k. purchasing or possessing a firearm.
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.
injuring, killing, torturing, or neglecting, or threatening to injure, kill, torture, or neglect any animal in which petitioner
has an ownership interest.
**
l. other:
(including a rifle, pistol, or revolver).
the civil and criminal contempt powers of the court. If found guilty of a violation, the respondent shall be imprisoned for
not more than 93 days and may be fined not more than $500.00.
b. If the respondent is less than 17 years of age, violation of this order subjects the respondent to immediate
apprehension or being taken into custody. If found guilty of a violation, the respondent shall be subject to the dispositional
alternatives listed in MCL 712A.18.
9. As a result of this order, federal and/or state law may prohibit you from possessing or purchasing ammunition or a firearm
10. a. If the respondent is 17 years of age or more, violation of this order subjects the respondent to immediate arrest and to
11. This order is effective when signed, enforceable immediately, and remains in effect until
.
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.
who will enter it into the LEIN.
12. The court clerk shall file this order with
13. The respondent may file a motion to modify or terminate this order. If this is an ex parte order, a motion to modify or
14. A motion to extend the order must be filed 3 days before the expiration date in item 11 or else a new petition must be filed.
15. Other:
terminate this order and a requrest for a hearing must be made within 14 days after the respondent has been served or
has received actual notice of this order. Forms and instructions are available from the clerk of the court.
Name of law enforcement agency
,
Petitioner’s name
C
Respondent’s name
v
Date and time issued
Judge
STATE OF MICHIGAN
JUDICIAL CIRCUIT
COUNTY
PERSONAL PROTECTION ORDER AGAINST
A MINOR (DOMESTIC RELATIONSHIP)
EX PARTE
PAGE 2 OF 2
CASE NO.
Approved, SCAOCourt telephone no.Court addressORIMI-ABCC 376M (7/16) PERSONAL PROTECTION ORDER AGAINST A MINOR (Domestic Relationship), Page MCL 600.2950, MCL 712A.2(h), MCR 3.705, MCR 3.70618 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) PROOF OF SERVICE
Case No.
Personal Protection Order
Against a Minor
TO PROCESS SERVER: You must serve the 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
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 against a minor by:
personal service
registered mail, delivery restricted to the respondent and the parent(s), guardian(s), or custodian(s)
of the respondent (return receipt attached) on:
Name of respondent
Complete address of service
Day, date, time
Name of parent/guardian/custodian
Complete address of service
Day, date, time
Name of parent/guardian/custodian
Complete address of service
Day, date, time
Law enforcement agency
Complete address of service
Day, date, time
MCR 2.105(A)
I have personally attempted to serve a copy of the personal protection order against a minor 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.
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 against a minor order on
Day, date, time
Signature of respondent
.
Signature of respondent’s parent/guardian/custodian
Signature of respondent’s parent/guardian/custodian
