THE PEOPLE OF

 The State of Michigan

 
 

In the matter of 
 

   

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

Defendant’s name, address, and telephone no.

v

CTN/TCN

SID

DOB
Put DOB in Ref. No. 
row 1 on MC 97. 

D   1. On 
 
 
     
E   2. a. 

 

 I was convicted of the following offense 

 

 I was not confined for this offense.   

 I completed the term of confinement for this offense on 

 I am a Tier I offender and at least 10 years have passed since I was convicted or since I was released from

 

 I am a Tier III offender and at least 25 years have passed since I was adjudicated or since I was released from

              confinement for the conviction. OR
         
              confinement for the adjudication. AND
              1) I have not been convicted of any felony or any offense listed in MCL 28.722(r), (t), or (v) since the date of 
                  my conviction or the date of my release from any confinement for this conviction.
              2) I have successfully completed my assigned period of supervised release, probation, or parole without 
                  revocation at any time of that supervised release, probation, or parole.
 3) I was ordered to complete a sex offender treatment program and I successfully completed that program.
         
 b. I was convicted of an offense listed in MCL 28.722(r), (t), or (v), and the conviction was for an offense that was
     
              the result of a consensual sexual act between me and the victim, and the victim was 13 years of age or older   
              but less than 16 years of age at the time of the offense and I was not more than 4 years older than the victim. 
     
 c.  I was convicted of a violation of MCL 750.158, 750.338, 750.338a, 750.338b, or 750.520c(1)(i) as a result of a
              consensual act and the victim was 16 years of age or older and not under my custodial authority at the time    
              of the violation. 
     
              registration and the offense no longer requires registration.   
     
              years of age at the time of the offense.
  3. I request that the court issue an order to discontinue sex offender registration as provided by law.

 d. I was registered under the Sex Offenders Registration Act before July 1, 2011 for an offense that required

 e. I was adjudicated as a juvenile for an offense listed in MCL 28.722(r), (t), or (v), and I was less than 14  

 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 

                                                                                           F Signature

G  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.

 .
 .

 . 
 

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STATE OF MICHIGANJUDICIAL DISTRICTJUDICIAL CIRCUITCOUNTY PETITION TO DISCONTINUE SEX OFFENDER REGISTRATIONCASE NO. and JUDGEORIMI-Court addressCourt telephone no.Approved, SCAOForm MC 406a, Rev. 12/21MCL 28.728cPage 1 of 2Distribute form to:CourtDefendant/JuvenileProsecuting officialReturnBCA before 

 .

 

NOTE: The victim has the right to attend this hearing and to make a written or an oral statement to the court before any decision regarding this petition is 
made. The victim is not required to appear at this hearing against his or her will.

If you require accommodations to use the court because of a disability or if you require a foreign language interpreter to fully participate in court proceedings, 
please contact the court immediately to make arrangements. 

CERTIFICATE OF MAILING

 served a copy of this petition and notice of hearing on the prosecuting official by first-class mail addressed to his/her last-
known addresses as defined by MCR 2.107(C)(3). I declare under the penalties of perjury that this certificate of mailing has 
been examined by me and that its contents are true to the best of my information, knowledge, and belief.

I  

Date

 

Petitioner/Attorney signature 

 

 

 

 
 

 
  at 

Location

  I

Petition to Discontinue Sex Offender Registration 
Page 2 of 2

(12/21) 

Case No. 
 

NOTICE OF HEARING

H   A hearing will be held on the above petition to discontinue registration on 

Date and time