Free pcm224.pmd - Michigan

Approved, SCAO

JIS CODE: PJA

STATE OF MICHIGAN PROBATE COURT COUNTY
CIRCUIT COURT - FAMILY DIVISION

FILE NO. PETITION FOR JUDICIAL ADMISSION

In the matter of 1. I,
Name (type or print) State your interest/relationship

XXX-XXLast four digits of SSN

, am interested in this matter and make this petition as .

2. The individual named above, born
Date

, is a resident of
County City State Zip

, .

Michigan, and can be found at
Address

3. The individual is a person with mental retardation and can be reasonably expected within the near future to intentionally or unintentionally seriously physically injure self or another person and has overtly acted in a manner substantially supportive of that expectation. 4. This allegation is based upon: a. My personal observation of the individual doing the following acts and saying the following things:

(PLEASE SEE OTHER SIDE)
Do not write below this line - For court use only

PCM 224 (9/07)

PETITION FOR JUDICIAL ADMISSION

MCL 330.1516

5. b. The following conduct and statements by the individual, which I have been informed others have seen or heard:

by:
Witness name Complete address Telephone no.

by:
Witness name Complete address Telephone no.

5. Persons interested in these proceedings are:
NAME RELATIONSHIP ADDRESS TELEPHONE NO.

6. The individual will not comply with an order for examination because . I REQUEST 7. The court order the individual to be examined at
Center

.

8. The court order a peace officer to take the individual into protective custody and transport him/her immediately to for examination.
Center

9. The individual be determined by the court to be a person meeting the criteria for judicial admission.

I declare under the penalties of perjury that this petition has been examined by me and that its contents are true to the best of my information, knowledge, and belief.

Signature of attorney Name (type or print) Address City, state, zip Telephone no. Bar no.

Date Signature of petitioner Address City, state, zip Telephone no.