If you have decided to file a complaint with children's protective services I have the following form that I recommend that you use when doing so.

Please keep in mind that Children's Protective Services (CPS) is bound by law to keep confidential the names of persons reporting child abuse. What this usually means is that child abuse complaints are kept confidential and the records are often not disclosed under the law requiring that CPS protect the confidentiality of the person making the complaint. (The reporting person)

I recommend that if your are serious about filing a CPS complaint to protect a child then you should make it clear that except during the investigation and after a specified period of time you waive your right to the states protection of confidentiality. The reasons for this is:

1) So that there is a clear intent on your part to protect the child you are reporting,

2) So that it makes it more difficult for the CPS Agency to cover up a credible complaint of child abuse.

3) It has often been noted by many experts that the confidentiality laws are abused to cover up agency negligence, by the (CPS) agency, instead of protecting the reporting person's confidentiality, or the child.

This form should resolve that issue and protect the child. Always make your report in writing, have it notarized, and sent Certified US Mail, with return delivery receipt. And also make sure that you make and keep at least two extra copies of the complaint that you file.

It is also an excellent idea to state the specific CPS Law with which you are making the complaint. When making the complaint try to be as accurate as possible with specific names of all parties, addresses, phone numbers, dates, and incidents.

As a matter of fact I highly recommend filing a Children's Protective Services Complaint with the County Court Clerk and get the Court Clerk's Official File Stamp on the CPS Complaint before sending the written complaint to the CPS Agency (This complaint then becomes a public record). If there is an existing file with the child's name in it at the Court Clerk's Office, such as a Probate Case, visitation, paternity, or custody case file, then this is the place to file a copy to make the CPS Complaint a public record. If there is no existing court file then there may be an additional cost to file a written CPS Complaint with the Court Clerk.

TO: The name, address and telephone number of the agency you are making the complaint to.

From: Your complete name and address and phone number.

Date: The date you are making and mailing the complaint.

Monday, August 5, 1997

Please take notice:

1) This is a Children's Protective Services Complaint filed under MCL 722.622 Sec.2(c)(d)

2) On August 1, 2, & 3, 1997, Diana Smith, a minor child born on February, 25, 1990, age 7 years old, who resides with her custodial parent at 653 West Maple Street, Lansing, Michigan 51555, (555)-555-5555 spent a weekend visitation at 123 Brookview Terrace, Lansing Michigan 51555. (444)-444-4444 with her paternal father, Bob Smith.

3) During this visit I observed the child to have:

a) Excessive sores which the child had been picking at and also a large bruise on her left leg and an abrasion on her head.

b) Open sores and wounds along both her arms, elbows, and shoulders, with several areas which appeared to be healed scar tissue from previous similar wounds.

c) Swollen appearance to her eyes like a lack of sleep, or excessive crying.

4) On Sunday, August 3, 1997, I observed Diana inflicting wounds to herself, in her father's backyard, with a broken piece of glass.

5) Shortly before the child was to return home I heard her begging her father not to return her to her mothers house and explaining she did not want to get a spanking when she returned. While the child and her father were preparing to get in the car the child called her father stupid for not believing her and proceeded to throw a temper tantrum and the father had to carry Diana to the car.

6) On a previous visitation weekend, July 26, 1997, Diana was playing with my daughter, Mary, and I overheard Diana say to Mary that her mother's boyfriend was making her stay in the basement with the lights turned out and that she was afraid of the dark.

7) During the same weekend Diana had used the bathroom at my house and when she was done I saw that she had had an accident and smeared some of her own feces on her arm, near the wrist. When I pointed out to the child she needed to clean herself up better she suddenly cringed in fear and tensed up. Diana then turned around and started to lick her own feces off of herself. I tried to stop her and when I reached out to touch Diana she begged me not to spank her and tried to run away from me.

8) These incidents were observed by me and my husband and we have tried to talk to Diana's father about this and he has stated that Diana' mother said they went camping and Diana came back with a lot of mosquito bites that she would not leave alone. Diana has had healed scars on her for about two months now, each time I have seen her when she plays with my daughter. Diana's father has said that Diana did have some hygiene problems and had tried to talk to Diana's mother about it.

9) I hereby waive my right to have my confidentiality protected by the State of Michigan and Children's Protective Services and request that during the investigation my name not be released until 14 days after the date of this complaint. After 14 days from the date of this complaint I grant access to my report to any person named in that record, or report, or any law enforcement agency or investigating agency reviewing to this complaint.

"I swear, affirm, under the penalties of perjury that these representations are true, that I have personal knowledge of the facts stated herein, and that I am competent to testify to the facts stated herein, and that this document is admissible in court as evidence."

DATED: August 5, 1997

SIGNED:_________________________

.....................Bridgette Citizen

Subscribed and sworn to before me this 5th Day of August, 1997

Notary of Public _____________________. My commission expires________________

Resident of ______________________County, State of Michigan.

CERTIFICATE OF SERVICE

I hereby certify that a copy of this Children's Protective Services Complaint was forwarded to the (Name of County) Children's Protective Services at (mailing address) (zip code) by certified US Mail, return receipt requested on August 5, 1997. Certified US Mail Article No: P 060 988 311.

DATED: August 5, 1997

SIGNED:__________________________

....................Bridgette Citizen

[MAIN PAGE] - [SAMPLE CHILD ABUSE COMPLAINT] - [LEGAL RESEARCH] - [CHILD ABUSE ORGANIZATIONS]