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Order To Take Child(ren) Into Protective Custody (Child Protective Proceedings) JC 05b - Michigan
| Order To Take Child(ren) Into Protective Custody (Child Protective Proceedings) Form. This is a Michigan form and can be used in Juvenile Statewide . |
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Approved, SCAO JIS CODE: OTC STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION CASE NO. ORDER TO TAKE CHILD(REN) INTO PETITION NO. PROTECTIVE CUSTODY COUNTY (CHILD PROTECTIVE PROCEEDINGS), PAGE 1 Court telephone no. Court address 1. In the matter of name(s), alias(es), DOB (see reverse side for other identifying information) 2. Date of entry of order: Judge/Referee: Bar no. Upon presentation of proofs as required by the court, IT APPEARS: 3. a. There are reasonable grounds for this court to remove the child(ren) from the parent(s), guardian, or legal custodian in compliance with MCL 712A.2(b) and MCR 3.963(B) MCR 3.974(B)(1) because conditions or surroundings of the child(ren) are such as to endanger the health, safety, or welfare of the child(ren), and it is contrary to the welfare of the child(ren) to remain in the home because: 4. b. The child(ren) has/have already been removed from the parent(s), guardian, or legal custodian and is/are absent without leave from court-ordered placement. a. Reasonable efforts to prevent removal of the child(ren) from the home were not made. b. Reasonable efforts were made to prevent removal of the child(ren) from the home. Those efforts include: (Specify.) 5. a. Reasonable efforts are not required to prevent the child(ren)'s removal from the home due to the mother father subjecting the child(ren) to the aggravated circumstance(s) of as provided in section MCL 722.638(1) and (2), and as evidenced by . the mother's father's conviction for murder of another child of the parent. the mother's father's conviction for voluntary manslaughter of another child of the parent. the mother's father's conviction for aiding or abetting in the murder or manslaughter of another child of the parent, attempting to murder the child(ren) or another child of the parent, or conspiring or soliciting to commit the murder of the child(ren) or another child of the parent. the mother's father's conviction for felony assault that resulted in serious bodily injury to the child(ren) or another child of the parent. the mother's father's involuntary termination of parental rights to a sibling of the child(ren). b. Reasonable efforts to preserve and reunify the family to make it possible for the child(ren) to safely return home are not required because the parent subjected the child or another child of the parent to one of the circumstances stated above. OR still recommended because: (When item 5 is checked, schedule a permanency planning hearing within 30 days of this determination.) 6. The child(ren) is/are Indian as defined in MCR 3.002(5), subject to the exclusive jurisdiction of a tribal court but temporarily located off the reservation, and removal of the child(ren) is necessary to prevent imminent physical harm to the child(ren). (SEE SECOND PAGE) Do not write below this line - For court use only MCL 712A.2(b), MCL 712A.15(4), MCL 712A.19a(2), MCR 3.963(B), (C), MCR 3.974(B)(1), MCR 3.979(F)(2) JC 05b (9/10) ORDER TO TAKE CHILD(REN) INTO PROTECTIVE CUSTODY (CHILD PROTECTIVE PROCEEDINGS), PAGE 1 American LegalNet, Inc. www.FormsWorkFlow.com Approved, SCAO JIS CODE: OTC STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION CASE NO. ORDER TO TAKE CHILD(REN) INTO PETITION NO. PROTECTIVE CUSTODY COUNTY (CHILD PROTECTIVE PROCEEDINGS), PAGE 2 Court telephone no. Court address In the matter of IT IS ORDERED: TO: (specify whether child protective services worker, an officer, or other person deemed suitable by the court pursuant to MCR 3.963[B][1]) 7. The child(ren) shall be taken into protective custody and a. placed with/returned to the Department of Human Services for care and supervision. b. placed at treatment until medically released to for placement at Placement shall continue until resumption of the next scheduled hearing. 8. To effect this order you are authorized to enter the premises located at . 9. The parent(s), guardian, or legal custodian of the child(ren) shall be directed to appear for a preliminary hearing in this matter to be held on Date for medical observation and . at Time (if known) at Location . (Item 9 is not applicable for orders to take children into custody who are absent without leave from court-ordered placement.) 10. This authorization to enter the premises and take the child(ren) into protective custody expires Enter on LEIN . Date Judge NOTE to parent(s), guardian, or legal custodian: If you require special accommodations to use the court because of a disability or if you require a foreign language interpreter to help you fully participate in court proceedings, please contact the court immediately to make arrangements. JC 05b (9/10) ORDER TO TAKE CHILD(REN) INTO PROTECTIVE CUSTODY (CHILD PROTECTIVE PROCEEDINGS), PAGE 2 American LegalNet, Inc. www.FormsWorkFlow.com IDENTIFYING INFORMATION Name Name Name Name Home address Father's name Mother's name Pickup radius Address Address Race Race Race Race Sex Sex Sex Sex Height Height Height Height City City City Court ORI Weight Weight Weight Weight Hair color Hair color Hair color Hair color State State State Eye color Eye color Eye color Eye color Zip Zip Zip Date of birth Date of birth Date of birth Date of birth Telephone number Telephone number Telephone number Statewide Other: MI Reason for removal is stated in item 3 on page 1 of the order to take child(ren) into protective custody. OFFICER'S CUSTODY STATEMENT AND RECORD OF NOTIFICATION 1. I certify and return that I have taken Child(ren)'s name(s) into custody on to Date at Time and have delivered the child(ren) . Place of temporary placement 2. I notified attempted to notify the parent(s), guardian, or legal custodian listed below that the child(ren) has/have been taken into protective custody and that a preliminary hearing will be held on Date and time at Location . NAME Father Mother Guardian/Legal custodian Other METHODS USED (reasons for failure to notify must be noted) DATE TIME I declare that this custody statement has been examined by me and that its contents are true to the best of my information, knowledge, and belief. Date Signature Agency name American LegalNet, Inc. www.FormsWorkFlow.com
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