Free IN THE SUPERIOR COURT FOR THE STATE OF ALASKA - Alaska

IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT __________________ In the Matter of the Necessity for the Hospitalization of: , Respondent. ) ) ) ) ) )

Case No. AFFIDAVIT IN SUPPORT OF MOTION TO DISMISS PETITION

I, being duly sworn, state as follows: 1. I am the 2. Because of the following facts, I believe that the petition of should be dismissed:

in this matter.

Date

Signature Print Name and Title

Subscribed and sworn to or affirmed before me at on __________________________, 20_______.

, Alaska,

(SEAL) Clerk of Court, Notary Public or other person authorized to administer oaths. My commission expires: I certify that on ___________________ a copy of this affidavit was sent to: court (original) respondent's attorney attorney general respondent treatment facility Other: By: ______________________ Petitioner MC-506 (3/01)(cs) AFFIDAVIT IN SUPPORT OF MOTION TO DISMISS PETITION