STATE OF MICHIGAN
JUDICIAL DISTRICT
JUDICIAL CIRCUIT
COUNTY
JUDGMENT OF SENTENCE
COMMITMENT TO JAIL
CASE NO. and JUDGE
ORI
MI-
Court address Court telephone no.
Police Report No.
THE PEOPLE OF
The State of Michigan
v
Defendant’s name, address, and telephone no.
CTN/TCN SID DOB
Approved, SCAO
Form MC 219, Rev. 6/23
MCL 600.4803, MCL 765.15(2), MCL 769.1k, MCL 769.3, MCL 769.16a,
MCL 775.22, MCL 780.766, MCL 780.826, MCR 6.427
Page 1 of 2
Distribute form to:
Court
Jail
Michigan State Police CJIC
Defendant
Prosecutor
THE COURT FINDS:
1. The defendant was found guilty on
Date
of the crime(s) stated below:
Count
CONVICTED BY
DISMISSED
BY* CRIME
CHARGE CODE(S)
MCL citation/PACC CodePlea* Court Jury
*Insert “G” for guilty pleas, “NC” for nolo contendere, or “MI” for guilty but mentally ill, “D” for dismissed by court, or “NP” for dismissed by prosecutor/
plaintiff.
2. The defendant was represented by an attorney:
.
was advised of right to counsel and appointed counsel and knowingly, intelligently, and voluntarily
waived that right.
3. Conviction reportable to Secretary of State.** The defendant’s driver’s license number is
.
4. Sanctions are reportable to State Police.** Revoked. Suspended
days. Restricted
days.
**(see page 2)
5. HIV testing is required and has been completed. Sex offender registration is required and has been completed.
6. The defendant has been fingerprinted according to MCL 28.243.
7. A DNA sample is already on file with the Michigan State Police from a previous case. No assessment is required.
IT IS ORDERED:
8. Probation is revoked.
9. Deferred status is revoked. HYTA status is revoked.
Judgment of Sentence/Commitment to Jail (6/23)
Page 2 of 2
Case No.
IT IS ORDERED (continued):
10. The defendant is sentenced to jail as follows: Report at
Time
.
Count
Date Sentence
Begins
Sentenced Credited To Be Served Release Authorized
for the Following Purpose
Release Period
Mos. Days Mos. Days Mos. Days From To
Upon payment of fine and costs..........................
To work or seek work...............................................
For attendance at school.........................................
For medical treatment..............................................
Other:
11. Sentence(s) to be served consecutively to (If this item is not checked, the sentence is concurrent.)
each other. case number(s)
.
12. The defendant shall pay:
State Minimum Crime Victim Restitution DNA Assess. Court Costs Attorney Fees Fine Other Costs Total
$ $ $ $ $ $ $ $ $
The due date for payment is
. Fine, costs, and fees not paid within 56 days of the due
date are subject to a 20% late penalty on the amount owed. If you are not able to pay due to financial hardship,
contact the court immediately to request a payment alternative. MCR 6.425(D)(3).
The defendant shall serve
days in jail for failure to pay on time, as part of a conditional sentence. Prior to
enforcement of jail time for failing to pay, the court must determine the defendant’s ability to pay.
13. The defendant shall be placed on probation for
months and abide by the terms of probation. (See separate order.)
14. The defendant shall complete the following rehabilitative services.
Alcohol Highway Safety Education Treatment ( outpatient, inpatient, residential, mental health).
Specify:
15. Other:
16. The vehicle used in the offense shall be immobilized or forfeited. (See separate order.)
Judge/Magistrate signature and date
**Currently convictions are reportable to the Secretary of State under:
• MCL 257.625(21)(a)
• MCL 257.732
• MCL 324.80131
• MCL 324.81134(20)
• MCL 324.82157
**Sanctions are reportable to the State Police under:
• MCL 257.625(21)(b)
