Free (pc109.pdf) - Michigan

Approved, SCAO

STATE OF MICHIGAN JUDICIAL CIRCUIT COURT COUNTY

AFFIDAVIT TO ACCOMPANY PETITION FOR TRANSPORT AND/OR TEMPORARY DETENTION

CASE NO.

In the matter of

1. I believe
Name (type or print)

to be a carrier of because of the following facts:

specify infectious agent or serious communicable disease or infection

2. I believe the individual is a health threat to others because of the following facts:

3. The individual requires the following services at an emergency care or treatment facility:

4. An emergency order is necessary because of the following facts:

Date Affiant's signature Name (type or print) Address City, state, zip Telephone no.

Subscribed and sworn to before me on
Date

, Signature:

County, Michigan.

My commission expires:
Date

Notary public

Do not write below this line - For court use only

MCL 333.5207(1),(2); MSA 14.15(5207)(1), (2), MCR 5.782 PC 109 (6/98)

AFFIDAVIT TO ACCOMPANY PETITION FOR TRANSPORT AND/OR TEMPORARY DETENTION