Defendant’s name, address, and telephone no.

v

CTN

SID

DOB

Probation officer

Offense

Term

THE PEOPLE OF

 The State of Michigan

 
 

Rehabilitation goals of probation

 Judgment of guilt is deferred* under:

     
     
     
     

 MCL 333.7411, Controlled Substance Act
 MCL 750.451c, Human Trafficking Victim
 MCL 750.430, Practicing under the Influence
 MCL 750.350a Parental Kidnapping Act (for felonies only)

 MCL 769.4a, Spouse Abuse Act
 MCL 762.14, Youthful Trainee Status
 MCL 600.1070, Drug Treatment Court

 MCL 600.1095, Mental Health Court
 MCL 600.1206, Veterans Court
 MCL 436.1703, Minor in Possession

 Under 18 USC 922(g)(8), the court found, at a hearing, that the defendant represents a credible threat to the physical

  safety of one or more persons as defined in 18 USC 922(g)(8) and 18 USC 921(a)(32) and named in item 10.
  Needed for NCIC entry.

IT IS ORDERED that the defendant be placed on probation under the supervision of the probation officer named above for 
the term indicated, and the defendant shall:
1. Not violate any criminal law of any unit of government.
2. Not leave the state without the consent of this court.
3. Make a truthful report to the probation officer monthly, or as often as the probation officer may require, either in person, 
  virtually, or in writing, as required by the probation officer.
4. Notify the probation officer immediately of any change of address or employment status.

 5. Not purchase or possess a firearm. (Needed for NCIC entry.)

6. Pay the following:

Court Costs:
     Crime Victim Assessment.... $

     Restitution............................ $

     Costs....................................................... $

     State Minimum Costs........... $

     Other (including any DNA assessment)... $

     Fines....................................................... $

 

Approved, SCAO
Form MC 243, Rev. 9/22
MCL 600.4803, MCL 769.1a, MCL 771.1 et seq., MCL 775.22, MCL 780.826, 
MCR 6.441, MCR 6.445, 18 USC 922(g)(8)
Page 1 of 3

Court Costs Sub-Total:

Supervision Fee:

Total

$

$

$

Distribute form to: 
Court
Probation department
Defendant
Prosecutor
Law enforcement agency (when applicable)
Court LEIN copy (when applicable)
Copy for incarcerating agency as needed

STATE OF MICHIGANJUDICIAL DISTRICTJUDICIAL CIRCUITORDER OF PROBATIONCASE NO. and JUDGEORIMI-Court addressCourt telephone no. b. The total amount due shall be paid in installments of $ 

 

 starting on 

Date

        and paid in full by the due date stated in the judgment of sentence or by 

 
  Fines, costs, and fees not paid within 56 days of the date owed or of any installment payment date are subject to a 20% 
 
8. Supervision fees are to be paid to the   

 State of Michigan (MDOC)    in the amount of $ 

late penalty on the amount owed.

 court   

 . 

 .

 

The fee is  payable immediately. 

 The total amount due may be paid in installments of $ 

per 

 

 starting on 

Date

 . 

 

 9. Comply with the attached wage assignment order.
 10.  Other: (Use this space for conditions for the protection of one or more named persons - also complete the LEIN section in item 12. See 
      below for required language when conditions are ordered pursuant to 18 USC 922[g][8].)

 

 

   

   

   

 

Order of Probation 
Page 2 of 3

(9/22)

7. Court costs must be paid as follows:
 

 a. The due date for court costs payment is 

 

Case No. 
 

 .

 per 
 

11.  Defendant 

 

 may be 

 

 is not 

  eligible for early discharge from probation under MCL 771.2.

 12. This order shall be entered into LEIN, is effective when signed, and expires on  

 .

 

Height

Weight

Race*

Sex*

Date of birth*

Driver’s license number

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.

Failure to comply with this order may result in a revocation of probation and incarceration. If you are not able to pay due to 
financial hardship, contact the court immediately to request a payment alternative. MCR 6.425(D)(3).
 

                     

                     

 
If the judgment of guilt is deferred as stated above, the clerk of the court shall advise the Michigan State Police Criminal Justice Information Center of the
disposition, except for Minor in Possession, as required under MCL 769.16a. A case in which judgment of guilt is deferred shall be maintained as a 
nonpublic record. *If the judgment of guilt is deferred and the defendant is incarcerated, the clerk of the court should also advise the incarcerating agency 
of nonpublic record status.

Judge/Magistrate signature and date

Required Language When Conditions are Issued Pursuant to 18 USC 922(g)(8):

Use the following language when the conditions involve an intimate partner of the defendant or child of the intimate partner 
or defendant as defined in 18 USC 922(g)(8) and 18 USC 921(a)(32).

 
 

      Defendant is restrained from harassing, stalking, or threatening, or engaging in other conduct that would place
      [insert name(s)] in reasonable fear of bodily injury.

For details about these conditions, see SCAO Administrative Memorandum 2008-02.

Case No. 
 

Order of Probation 
Page 3 of 3

(9/22)

NOTICE TO DEFENDANT:  

  1. 1/2 of the original probation period.
  2.  all required programming.

If you may be eligible for early discharge from probation under MCL 771.2 (see #11 above), you must complete the 
following before the court will consider whether to discharge you:

When these conditions are met, the probation department may (but is not required to) notify the court that you may be 
eligible for an early discharge from probation.  If the probation department does not provide this notice, and as long 
as you have not violated probation within the last 3 months, you may notify the court that you may be eligible for early 
probation discharge by completing form MC 512, Notice of Eligibility for Early Discharge from Probation, and filing it with 
the court. 

DEFENDANT’S ACKNOWLEDGMENT

I have read or heard the order of probation and have received a copy. I understand and agree to comply with this order. 
I also understand that federal and/or state law may prohibit me from possessing or purchasing ammunition or a firearm 
(including a rifle, pistol, or revolver) if the court found I represent a credible threat to the physical safety of a named person 
and/or explicitly prohibited (in item 10) the use, attempted use, or threatened use of physical force that would reasonably 
be expected to cause bodily injury to that named person.

Date

 

Defendant signature