In the matter of 

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

	 	 		 ┌		 	 	 	 	 	

	
1. TO:    

			

	

	

	

		┐

	 	 		 └		 	 	 	 	 	

	
			
2. YOU ARE ORDERED to appear in person before the court for a hearing on the allegations in the attached petition. The
  appearance of the child(ren) named above 
3. The date, time, and place of the hearing are:

  necessary.

 is not 

		┘	

 is 

 

 

	

	

	

	

4. The purpose of the hearing is
 
 
 
 

 to decide, at a trial, whether one or more of the statutory grounds alleged in the petition are true.
 to rule on a request that your parental rights over the child(ren) be terminated.
 to decide if you are the father of the child(ren) named above.
 other:

financially able to hire an attorney, you should contact the court immediately about a court-appointed attorney.

5. RIGHT TO ATTORNEY: As a respondent you have the right to be represented by an attorney. If you want an attorney, 
  you should hire one immediately so the attorney will be ready on the hearing date. If you want an attorney but are not 
 
6. RIGHT TO TRIAL BY JURY: If you want a jury to decide the facts at the trial, you must file a written request with the 
  court within 14 days after the court gives notice of the right to jury trial or 14 days after an appearance by an attorney, 
  whichever  is later, but no later than 21 days before trial. There is no right to a jury at a termination of parental rights 
  hearing.
7. RIGHT TO TRIAL BY JUDGE: Either a judge or a referee may decide the facts at a trial without a jury. If you want a 
judge to decide the facts at the trial, you must file a written request with the court within 14 days after the court gives 
 
  notice of the right to a judge or 14 days after an appearance by an attorney, whichever is later, but no later than 21 days 
  before trial.

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.

WARNING:	You	are	notified	that	this	hearing	may	result	in	a
temporary or permanent loss of your rights to the child(ren).

FAILURE TO APPEAR may subject you to the penalty for contempt of court, and a bench warrant may be issued for your 
arrest.

 

                     

Judge signature and date

Approved, SCAO
Form JC 21, Rev. 10/20
MCL 712A.13, MCR 3.911, MCR 3.912, MCR 3.915, MCR 3.920, MCR 3.928
Page 1 of 2

STATE OF MICHIGANJUDICIAL CIRCUIT - FAMILY DIVISIONCOUNTYSUMMONS: ORDER TO APPEAR(CHILD PROTECTIVE PROCEEDINGS)CASE NO.PETITION NO.JUDGECourt addressCourt telephone no.JIS Code: SUMSummons: Order to Appear (Child Protective Proceedings) 
Page 2 of 2

(10/20) 

Case No. 
 

PROOF OF SERVICE

TO  PROCESS  SERVER:  You  are  to  serve  the  summons  and  petition  in  accordance  with  MCR  3.920(B)(5)  and  the 
instructions of the court. You must make and file your return with the court clerk. If you are unable to complete service you 
must complete item 3 and 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 summons and petition, and the attachments listed below on: 

 I have attempted to serve the summons and petition, together with the attachments listed below, and have been 

  unable to complete service on:

Name

Date and time of service

Place or address of service

Attachments (if any)

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

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.

                     

 
Service fee
$
                     
 
Incorrect address fee
$
 

                     

Miles traveled

Miles traveled

Fee
$

Fee
$

Subscribed and sworn to before me on 
 
 

                     
                     

Date

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

                     

 

 

  
Signature

  
Name (type or print)

  
Title (if applicable)

TOTAL FEE
$

 

 

 

 

 

 

 

 

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 service of the summons and petition, together with

ACKNOWLEDGMENT OF SERVICE

Attachments

Signature

 on 

Date and time

 on behalf of 
 

 . 
 

 .

 .