IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT In the Matter of the Necessity for the Hospitalization of: ) ) ) ) ) Case No. ) ) NOTICE OF WITHDRAWAL ) OF PETITION AND REQUEST ) FOR DISMISSAL OF CASE Respondent. Date of Birth: , A petition was filed on (date) at am pm seeking an order authorizing involuntary hospitalization of the respondent named above pursuant to AS 47.30.700 et seq. Because the respondent voluntarily admitted himself or herself to the facility named below for treatment, there is no longer a need for a court order directing the respondent's involuntary hospitalization. For this reason, the petition previously filed is withdrawn and this request for dismissal has been filed. Alaska Psychiatric Institute Bartlett Regional Hospital Fairbanks Memorial Hospital PeaceHealth Ketchikan Medical Center Yukon-Kuskokwim Delta Reg. Hospital Date Signature Print Name and Title Phone Number E-mail Address ORDER Fax Number IT IS SO ORDERED. The petition is dismissed. If an Order Authorizing Hospitalization for Evaluation was entered in this case, that order is hereby vacated. Date I certify that on a copy of this order was sent or given to: Respondent Parent/Guardian PDA AGO by Superior Court Judge Print Name MC-413 (2/17)(cs) NOTICE OF WITHDRAWAL OF PETITION AND REQUEST FOR DISMISSAL OF CASE AS 47.30.700 et seq. American LegalNet, Inc. www.FormsWorkFlow.com