Personal Protection Order (Nondomestic) - Michigan
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1
2
3
4Complete items A through B using the instructions. Fill
out the form by tabbing to each item or moving the mouse
Original - Court
3rd copy - Petitioner (pink)
to each item. Select check box items with the mouse.
1st copy - Law enforcement agency (file) (green)
4th copy - Return (yellow)
Approved, SCAO
2nd copy - Respondent (blue)
5th copy - Return (goldenrod)
STATE OF MICHIGAN
CASE NO.
PERSONAL PROTECTION ORDER
JUDICIAL CIRCUIT
(NONDOMESTIC)
COUNTY
EX PARTE
Court address
Court telephone no.
ORI
MI-
A
Petitioner's name
Respondent's name, address, and telephone no.
v
Address and telephone no. where court can reach petitioner
Address and telephone no. where court can reach respondent
Full name of respondent (type or print) *
Driver's license number (if known)
B
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:
Bar no.
1. This order is entered
without a hearing.
after hearing.
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.
is prohibited from
Full name of respondent
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.
Judge
Date and time issued
PERSONAL PROTECTION ORDER (NONDOMESTIC)
MCL 600.2950a, MCR 3.705, MCR 3.706
CC 380 (3/12)
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