In the matter of 

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

Regarding alleged abuser        Last name                               First name                               Middle initial

Relationship to child

Height Weight Race

Sex

Date of birth or age

Hair color Eye color

Driver’s license no.

Other identifying information

 

 

  Judge/Referee: 

1. Date of hearing: 
2. Notice of hearing was given as required by law.
THE COURT FINDS:
3. A petition alleging abuse of the child(ren) has been authorized and there is probable cause to believe the parent, 
  guardian, legal custodian, or other person committed the alleged abuse.
4. The alleged abuser's presence in the home presents a substantial risk of harm to the child(ren)'s life, physical health, or 
  mental well-being.
IT IS ORDERED:
5. The alleged abuser named above shall

 

 a. leave the home at 

 

        and must not subsequently return until further order of the court.  This individual shall have no contact with the 
        child(ren) named above except as follows:

 as appropriate support to maintain a suitable home environment for the child(ren).

c.  surrender any firearms or potentially dangerous weapons to 

 .

Name of local law enforcement agency

 b. pay $ 
 

6. Other:

 
 
 

 

   

7. This order is valid from 
 until 
  alleged abuser receives notice.  A violation of the terms and conditions subjects the alleged abuser to criminal contempt 
  of court. If found guilty of violating this order, the alleged abuser may be jailed for up to 90 days and fined up to $500.00.

 and is effective when the 

 

 

8. This order shall be entered into LEIN.

 

                     

Recommended by:

Referee signature and date

 

                     

Approved, SCAO
Form JC 65, Rev. 12/22
MCL 712A.13a, MCL 764.15f
Page 1 of 1

Judge signature and date

Distribute form to: 
Court 
Respondent 
Law Enforcement Agency

STATE OF MICHIGANJUDICIAL CIRCUIT - FAMILY DIVISIONCOUNTYORDER REMOVING ALLEGED ABUSERFROM CHILD’S HOME(CHILD PROTECTIVE PROCEEDINGS)CASE NO.PETITION NO.JUDGECourt addressCourt telephone no.PCS Code: OAATCS Code: ORH