Approved, SCAO
Form MC 97, Rev. 9/20
MCR 1.109
Page 1 of 1
STATE OF MICHIGAN
JUDICIAL DISTRICT
JUDICIAL CIRCUIT
COUNTY PROBATE
PROTECTED PERSONAL
IDENTIFYING INFORMATION
CASE NO. and JUDGE
Court address Court telephone no.
JIS Code: PPI
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 defendant, respondent, or decedent. If
the person is a plaintiff, petitioner, or other individual, use form MC 97a.
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 97 is being filed with:
Printed name of individual completing form and date
Instructions: Provide the name of the person that the PII applies to, followed by the specific PII that is required to be provided. For Other, specify the
type of PII in addition to the PII itself. Use the below reference number (Ref. No.) in the public document in place of the protected PII. For example,
insert “Ref. No. 1” in place of the DOB in the public document.
Ref.
No.
Name (required)
1
Date of birth
2
National ID no. / Last 4 digits of SSN
XXX-XX-
3
Driver’s License / State-issued ID no.
4
Passport no.
5
Other
Ref.
No.
Instructions: List the name of the financial institution and the account number. List the paragraph that references the account, if needed for
clarity. Use reference number (Ref. No.) when necessary to refer to account in public documents.
6
Financial institution Account no. Paragraph no.
7
Financial institution Account no. Paragraph no.
8
Financial institution Account no. Paragraph no.
9
Financial institution Account no. Paragraph no.
