Michigan > Statewide > Juvenile
Petition (Child Protective Proceedings) JC 04b - Michigan
| Petition (Child Protective Proceedings) Form. This is a Michigan form and can be used in Juvenile Statewide . |
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Approved, SCAO JIS CODE: PET STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION COUNTY Court address ORI MI- PETITION (CHILD PROTECTIVE PROCEEDINGS), PAGE 1 Supplemental CASE NO. PETITION NO. Court telephone no. 1. In the matter of a. b. (State the name, county of legal residence, race, sex, and date and place of birth of each child, and indicate with whom the child lives.) Name of child and county of legal residence Race Sex Date and place of birth Living with: Father Other Father Mother Other c. Name of child and county of legal residence Race Sex Date and place of birth Living with: Father Mother Other d. Name of child and county of legal residence Race Sex Date and place of birth Living with: Father Mother Other e. Name of child and county of legal residence Race Sex Date and place of birth Living with: Father Mother Other f . Name of child and county of legal residence Race Sex Date and place of birth Living with: Father Mother Other g. Name of child and county of legal residence Race Sex Date and place of birth Living with: Father Mother Other h. Name of child and county of legal residence Race Sex Date and place of birth Living with: Father Mother Other 2. The names and addresses and other relevant information of the parents, guardian, legal custodian, or nearest known relative are as follows: If the father/mother/guardian or legal custodian is a respondent, place a check mark in the column R. Name each father's children and Name of child and county of legal residence Race Sex Date and place of birth Living with: indicate for which child the father is a legal father by placing (LF) after the name of each child. If there is no (LF) designation, the father is presumed to be the putative father of the named child. For example: John Doe (LF), Mary Doe, Susan Doe (LF). a. Father's name Name(s) of child(ren) b. Father's name Name(s) of child(ren) c. Father's name Name(s) of child(ren) d. Father's name Name(s) of child(ren) e. Father's name Name(s) of child(ren) f. Father's name Name(s) of child(ren) g. Mother's name h. Mother's name i. Nonparent adult respondent's name j. Guardian/Legal custodian's name R DOB R DOB DOB R DOB Address Address Address Address Telephone no. Telephone no. Telephone no. Telephone no. R DOB Address Telephone no. R DOB Address Telephone no. R DOB Address Telephone no. R DOB Address Telephone no. R DOB Address Telephone no. R DOB Address Telephone no. Mother JC 04b (9/11) (SEE SECOND PAGE) PETITION (CHILD PROTECTIVE PROCEEDINGS), PAGE 1 MCL 712A.2, MCR 3.903(A)(19), MCR 3.926(A), MCR 3.961 American LegalNet, Inc. www.FormsWorkFlow.com Approved, SCAO JIS CODE: PET STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION COUNTY Court address PETITION (CHILD PROTECTIVE PROCEEDINGS), PAGE 2 Supplemental CASE NO. PETITION NO. Court telephone no. In the matter of 3. a. There is no other pending or resolved action within the jurisdiction of the family division of the circuit court involving the family or family members of the minor. b. An action within the jurisdiction of the family division of circuit court involving the family or family members of the minor has been previously filed in Court, Case Number , was assigned to Judge , and remains is no longer pending. 4. The named child(ren) come within the provisions of MCL 712A.2(b)(1)-(5) as follows (check all that apply): See page 3 for specific allegations. is a/are member(s) of or eligible for membership in an Indian tribe, as stated in the allegations. Removal is requested below, and attached are details describing the active efforts made to provide remedial services and rehabilitative programs designed to prevent the breakup of the Indian family and documentation and attempts to identify the child's tribe. A military/nonmilitary affidavit is attached. The parent or other person legally responsible for the care and maintenance of the child(ren), when able to do so, neglected or refused to provide proper or necesary support, education, medical, surgical, or other care necessary for the child(ren)'s health or morals, or he/she has subjected the child(ren) to a substantial risk of harm to his or her mental well-being, or he/she has abandoned the child(ren) without proper custody or guardianship. The home or environment, by reason of neglect, cruelty, drunkenness, criminality, or depravity on the part of the parent, guardian, nonparent adult, or other custodian, is an unfit place for the child(ren) to live. The parent has substantially failed, without good cause, to comply with a limited guardianship placement plan for the child(ren) pursuant to MCL 700.5205. The parent has substantially failed, without good cause, to comply with a court-structured plan for the child(ren) pursuant to MCL 700.5207 and 700.5209. The child(ren) has/have a guardian pursuant to the estates and protected individuals code and the parent meets both of the following criteria: (i) the parent, having the ability to support or assist in supporting the child(ren), has failed or neglected, without good cause, to provide regular and substantial support for two years or more before the filing of the petition or, if a support order has been entered, has failed to substantially comply with the order for two years or more before the filing of the petition, and (ii) the parent, having the ability to visit, contact, or communicate with the child(ren), has regularly and substantially failed or neglected, without good cause, to do so for two years or more before the filing of the petition. 5. The reason(s) why it is contrary to the welfare of the child(ren) for the child(ren) to remain in the home are: (Attach separate sheets as needed.) 6. The reasonable effort(s) made to prevent the removal of the child(ren) include: (Attach separate sheets as needed.) (SEE THIRD PAGE) JC 04b (9/11) PETITION (CHILD PROTECTIVE PROCEEDINGS), PAGE 2 American LegalNet, Inc. www.FormsWorkFlow.com Approved, SCAO JIS CODE: PET STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION COUNTY Court address PETITION (CHILD PROTECTIVE PROCEEDINGS), PAGE 3 Supplemental CASE NO. PETITION NO. Court telephone no. In the matter of 7. The specific allegations are: (Attach separate sheets as needed.) 8. I request the court to a. refer the matter to alternative services. b. authorize this petition and take jurisdiction over the child(ren). Further, I request the court to issue an order removing the child(ren) the abuser from the home. c. terminate parental rights of father to child(ren)
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