Approved, SCAO

STATE OF MICHIGAN

JUDICIAL CIRCUIT
COUNTY

Court  address
ORI
MI-
A

Petitioner's name

Original - Court
1st copy - Law enforcement agency (file) (green)
2nd copy - Respondent (blue)

PERSONAL PROTECTION ORDER
(NONDOMESTIC)
EX PARTE

3rd copy - Petitioner (pink)
4th copy - Return (yellow)
5th copy - Return (goldenrod)

CASE NO.

Court  telephone  no.

Respondent's name, address, and telephone no.

Address and telephone no. where court can reach petitioner

Address and telephone no. where court can reach respondent

v

B

 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.

Date:

Judge:

1. This order is entered

without a hearing.

after hearing.

Bar no.

THE COURT FINDS:

2. A petition requesting an order to restrain conduct prohibited under MCL 750.411h and MCL 750.411i and/or MCL 750.411s

has been filed under the authority of MCL 600.2950a.

3. 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.

4. Respondent committed the following acts of willful, unconsented contact:  (State the reasons for issuance.)

IT IS ORDERED:
5.

Full name of respondent

is prohibited from

a. 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 the workplace or the 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 or 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.
threatening to kill or physically injure the petitioner.
purchasing or possessing a firearm.
other:

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.

6. Violation of this order subjects the respondent to immediate arrest and to the civil and criminal contempt powers of the

court. If found guilty, respondent shall be imprisoned for not more than 93 days and may be fined not more than $500.00.

7. 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.

8. The court clerk shall file this order with
who will enter it into the LEIN.
9. Respondent may file a motion to modify or terminate this order.  For ex parte orders, the motion must be filed within 14 days
after being served with or receiving actual notice of the order.  Forms and instructions are available from the clerk of court.

10. A motion to extend the order must be filed 3 days before the expiration date in item 7, or a new petition must be filed.

Date and time issued

Judge

CC 380   (3/12)   PERSONAL PROTECTION ORDER (NONDOMESTIC)

MCL 600.2950a, MCR 3.705, MCR 3.706

PROOF OF SERVICE

Case No.

Personal Protection Order
(Nondomestic)

TO PROCESS SERVER:  You must serve the 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

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)

AFFIDAVIT OF PROCESS SERVER
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 by

personal service on:

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

Name of respondent

Complete address of service

Day, date, time

Law enforcement agency

Complete address of service

Day, date, time

I have personally attempted to serve a copy of the personal protection order on the following respondent and have been unable
to complete service.

Respondent's name

Complete address of service

 I declare that the statements above are true to the best of my information, knowledge, and belief.

Service fee

Miles traveled Fee

$
Incorrect address fee Miles traveled Fee
$

$

$

TOTAL FEE
$

Signature

    Name (type or print)

Title

     ,

Subscribed and sworn to before me on

Date

  County, Michigan.

My commission expires:

Date

      Signature:

Deputy court clerk/Notary public

Notary public, State of Michigan, County of

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

.

Day, date, time

ACKNOWLEDGMENT OF SERVICE

Signature of respondent

MCR 2.105(A)

Form CC 380

PERSONAL PROTECTION ORDER
(NONDOMESTIC)

Use this form if you filled out form CC 377, Petition for Personal Protection Order (Nondomestic).

INSTRUCTIONS FOR COMPLETING "PERSONAL PROTECTION ORDER (NONDOMESTIC)"

Please print neatly.

Items A and B must be completed before you give this form to the court clerk.  Please read the instruction for each item.
Then fill in the correct information for that item on the form.

Fill in the "petitioner" and "respondent" the same way you did on form CC 377.  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.

Write in the respondent's name and as much of the other information as you know.  This information will help
the police 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).

The court will complete the rest of this form.

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.

A

B

•

•

Important:

If the respondent violates this personal protection order and is arrested, the court will set a date, time, and place for
a hearing on the charges against the respondent to be held within 72 hours after arrest.  The court or prosecutor is
responsible for giving you notice of this hearing.  If you are not notified within 24 hours of the arrest, contact the court
that issued this order.  If a hearing is not held within 72 hours, the respondent may be released from jail after posting
bond pending the hearing.

If the respondent violates this personal protection order and there is no arrest, use form CC 382, Motion and Order to
Show Cause for Violating Valid Personal/Foreign Protection Order.  This form is available from the circuit court clerk.