Michigan > Statewide > Probate > Guardianships and Conservatorships
Petition For Authority Place Individual With Developmental Disability In A Facility PC 664 - Michigan
| Petition For Authority Place Individual With Developmental Disability In A Facility Form. This is a Michigan form and can be used in Guardianships and Conservatorships Probate Statewide . |
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Approved, SCAO OSM CODE: PDA STATE OF MICHIGAN FILE NO. PETITION FOR AUTHORITY TO PLACE PROBATE COURT INDIVIDUAL WITH DEVELOPMENTAL COUNTY DISABILITY IN A FACILITY CIRCUIT COURT - FAMILY DIVISION In the matter of , an individual with a developmental disability 1. I, , am interested in this matter and make this petition as guardian of Name the individual. 2. The individual is presently residing at Address . City State Zip 3. It is necessary I be authorized by this court to admit the individual: a. temporarily for a period not to exceed 30 days to Name of center located at to receive clinical services. b. to , located at Name of center for up to 10 days for a preadmission examination and subsequent administrative admission if suitable. c. to , located at . Name of facility 4. A report and evaluation required by law and rule is filed with this petition. 5. The following are all the interested persons in this proceeding, none of which are under legal disability except as noted: NAME AGE RELATIONSHIP ADDRESS 6. I REQUEST that I be authorized to execute the necessary applications for the administrative admission of the individual to . Name of facility 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. Attorney signature Date Name (type or print) Bar no. Petitioner signature Address Address City, state, zip Telephone no. City, state, zip Telephone no. Do not write below this line - For court use only MCL 330.1100b; MSA 14.800(100b), MCL 330.1509; MSA 14.800(509), MCL 330.1510; MSA 14.800(510), MCL 330.1623; MSA 14.800(623), MCR 5.746 PC 664 (3/00) PETITION FOR AUTHORITY TO PLACE INDIVIDUAL WITH DEVELOPMENTAL DISABILITY IN A FACILITY
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