Affidavit And Petition For Personal Protection Order
This is a Michigan form that can be used for 17th Circuit within Local County, Kent.
Last updated: 8/16/2006
Personal Protection Order (PPO) Affidavit Instructions Hand Print or Type Only Please read these instructions carefully . The Respondent will receive a copy is afof fidavit so carth efully word this document . Please start on the front side of the affidavit. The Judge will need to know how you know this pe rson. Tell what has happened in the past and whats happening now. The Judge will require the dates on whthe violence occurred. Sich tay current; dont go back year s. The affidavit is all you have to convince the Judge of why the Court should be involved in your situati on. If you dont provide enough fa your cts thenPPO request could be denied. (Statutory requirements must b met ie n order to issue a PPO.) Do not sign the affidavit until you are personally interviewed by a PPO In- terviewer. The Interviewer must witness your signat ure. The PPO Interviewers Office cannot translate nor write your stateme nt. Please do your bestper Michigan Court Rule, your hand-printing must be legible . <<<<<<<<<********>>>>>>>>>>>>> 2 Personal Protection Order (PPO) Affidavit For Office Use Onl y Judge: 1st 2nd 3rd h 4t Petition 1st 2nd 3rd h 4t Amended Extension Permanent Case #: ____________________________ Start Story Here: Does Respondent own firearms? Yes No Dont Know Has Access Has Respondent threatened to harm/kill you with a gun? Yes No Does Respondents employment require firearm possession? Yes No Respondents Employers Address: ___________________________________________________________________ ______________________________________________________________________ Affiant Signature Date Print Nam e I have written this statement for the Petitioner at the Petitioners direction because Petitioner cannot: Read Write Speaks another language ________________________________ ___________________________________________(Sworn In) _____________________________________ Signature of Interpreter Print Name ________________________________________________________ ___ Phone Number w/ Area C ode _________________________________________________________________(Sworn I___ n) _________________________________________ Signature of Next Friend (If the Petitioner is a minor) Prin t Nam e Subscribed and sworn to before me on ____________________________, in the County of Kent, Michigan. My commission expires ___________________________. __________________________________________________ Nota ry Publ i c Signature <<<<<<<<<********>>>>>>>>>>>>> 3 Personal Protection Order (PPO) Affidavit Page 2 Please limit your statement to pages one and two. <<<<<<<<<********>>>>>>>>>>>>> 4 Personal Protection Order (PPO) Petition Instructions Please fill out the entire form following these instructions. Every section is numbered. Step 1Mark the Domesti or c Stalking box describing the situation that pertains to your relationship (The Petitioner) with other person (The Respondent). Step 2You are the Petitioner. Fill in your and fnameull addressIf. you are in hidi ( ng, do not put your address on the form.) Step 3The person you are filing against isRe tsphe ondent. Fill in the entire box in- cluding Respondents name, full address and description. Step 4Mark all the boxes that apply to your relationship with the Respondent. Step 5Indicate any other Court orders, judgments or pending cases between you and the Respondent. Please attach copiesese docum of th ents if issued in a County other than Kent or a State other than Michigan. (Police Reports are acceptable.) Step 6Attach your affidavit or other doc iufm provent iding additional information. Step 7Indicate acts raleady committe againd st you. ? For Domestic cases, mark all situatiothns at apply for A through Q. ? For Stalking cases, mark all situations that apply for H through Q. Step 8Do not sign the petition until your interview with the PPO Interviewer. Step 9Leave this section blank. <<<<<<<<<********>>>>>>>>>>>>> 5 For Court Use On ly STATE OF MICHIGAN th Judge Kent County-17 Judicial Circuit/FAMILY DIVISION 180 Ottawa Avenue NW Suite 3500 Grand Rapids MI 49503 616-632-5067 Petition for Personal Protection Order Step 1Type of PPO Case Domestic Relationship (See #4 for definition.) Stalking -Th e petitioner and respondent are not husband and wife, have not resided in the same household together, Case Number: have no children in common, and have had no intimate dating relationship with one another. (No relationship whatsoever.) Step 2Petitioner Step 3Respondent Under age 18 Under age 18 Name: ___________________________________________________ Name: ___________________________________________________ Address: _________________________________________________ Address: _________________________________________________ City, State, ZIP: ____________________________________________ City, State, ZIP: ____________________________________________ Phone #: (______)_______________________________________Phone #:___ (______)__________________________________________ Parent of Minor Respondent: _________________________________ Step 4The petitioner and respondent (mark all that apply): Respondents Height: _______ Weight: _______ Race: ____________ Were husband & wife, now divorced. Birthdate: __________ Hair color: __________ Eye color: __________ Are husband & wife. Years married: ______ The respondent is required to carry a firearm in the course of Have a child(ren) in common. # of children: ______ his/her employmen(tR.e spondent is in law enforcement/security guard/other.) Reside or resided in the same household. From ______ to __Nam____ e of Supervisor: ________________________________________ Have or have had an intimate dating relationship. Address: _________________________________________________ Other, please describe: ________________________________Phone #:__ (______)__________________________________________ Step 5Please indicate any other pending actions/s/judgmentorders/police reports in tahnis oy otr her court regarding these parties. Please provide case #, Police Rpts & AgNamencye of Court, County Name of Judge Step 6Additional Information I need a personal protection order because of events occurred or threatened. Please see attached. Step 7I ask the court to grant a personal protection ordeohir bpriting the respondent fromomest (D ic A-Q, Stalking G-Q): A-Entering onto the property wherever I live. I own rent my current residence. Other: _________________________________________________ _ B-The respondent has no property interest in the premi(Is not cos