Original - Court
1st copy - Respondent
2nd copy - Law Enforcement Agency
PCS CODE: OAA
Approved, SCAO
Copies as needed
TCS CODE: ORH
STATE OF MICHIGAN
CASE NO.
ORDER REMOVING ALLEGED ABUSER
PETITION NO.
JUDICIAL CIRCUIT - FAMILY DIVISION
FROM CHILD’S HOME
COUNTY
(CHILD PROTECTIVE PROCEEDINGS)
Court address
Court telephone no.
1. In the matter of
name(s), alias(es), DOB
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
2. Date of hearing:
Judge/Referee:
Bar no.
3. Notice of hearing was given as required by law.
THE COURT FINDS:
4. 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.
5. 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:
6. The alleged abuser named above shall
a. leave the home at
until further order of the court and have no contact with the child(ren) named above except as follows:
b. pay $
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
7. Other:
8. This order is valid from
until
and is effective when the 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.
9. This order shall be entered into LEIN.
Recommended by:
Referee signature
Date
Date
Judge
Do not write below this line - For court use only
MCL 712A.13a, MCL 764.15f
ORDER REMOVING ALLEGED ABUSER FROM CHILD’S HOME (CHILD PROTECTIVE PROCEEDINGS)
JC 65 (9/16)
Original - Court
1st copy - Respondent
2nd copy - Law Enforcement Agency
PCS CODE: OAA
Approved, SCAO
Copies as needed
TCS CODE: ORH
STATE OF MICHIGAN
CASE NO.
ORDER REMOVING ALLEGED ABUSER
PETITION NO.
JUDICIAL CIRCUIT - FAMILY DIVISION
FROM CHILD’S HOME
COUNTY
(CHILD PROTECTIVE PROCEEDINGS)
Court address
Court telephone no.
1. In the matter of
name(s), alias(es), DOB
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
2. Date of hearing:
Judge/Referee:
Bar no.
3. Notice of hearing was given as required by law.
THE COURT FINDS:
4. 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.
5. 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:
6. The alleged abuser named above shall
a. leave the home at
until further order of the court and have no contact with the child(ren) named above except as follows:
b. pay $
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
7. Other:
8. This order is valid from
until
and is effective when the 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.
9. This order shall be entered into LEIN.
Recommended by:
Referee signature
Date
Date
Judge
Do not write below this line - For court use only
MCL 712A.13a, MCL 764.15f
ORDER REMOVING ALLEGED ABUSER FROM CHILD’S HOME (CHILD PROTECTIVE PROCEEDINGS)
JC 65 (9/16)
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