Approved, SCAO
Form MC 97a, Rev. 9/20
MCR 1.109
Page 1 of 1
STATE OF MICHIGAN
JUDICIAL DISTRICT
JUDICIAL CIRCUIT
COUNTY
ADDENDUM TO
PROTECTED PERSONAL
IDENTIFYING INFORMATION
CASE NO. and JUDGE
Court address Court telephone no.
JIS Code: API
Plaintiff’s/Petitioner’s name
v
Defendant’s/Respondent’s name
In the matter of
This form is nonpublic because it contains personal identifying information (PII) that is protected from public inspection
under MCR 1.109(D)(9)(a). Use this form to provide PII only for a person who is a NOT a defendant, respondent, or
decedent. If the person is a defendant, respondent, or decedent use form MC 97.
Instructions:
• When PII (such as date of birth) must be filed with the court on a public document, DO NOT include it on that public
document. Instead, you must provide it on this form.
• Provide only the protected PII required for your particular case. For example, if you are filing a public document that
requires you to provide a date of birth to the court, complete only that field on this form.
Name of form/document that this MC 97a is being filed with:
Printed name of individual completing form and date
Ref.
No.
Instructions: Provide the name of the person that the PII applies to, followed by the specific PII that is required. For Other, specify the type
of PII in addition to the PII itself ‑ for example, Social Security No. XXXX. Use the below reference number (Ref. No.) in the public document in
place of the protected PII. For example, insert “Ref. No. XX” in place of the DOB in the public document.
10
Name DOB Other
11
Name DOB Other
12
Name DOB Other
13
Name DOB Other
14
Name DOB Other
15
Name DOB Other
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Name DOB Other
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Name DOB Other
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Name DOB Other
