Original - Prisoner 1st copy - Parole board 2nd copy - Prosecutor/Victim Approved, SCAO STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY 3rd copy - Prison/Facility 4th copy - Court (for proof from prison/facility) 5th copy - Court (for proof from prosecutor/victim) NOTICE TO PRISONER ON APPLICATION FOR LEAVE TO APPEAL DECISION OF PAROLE BOARD CIRCUIT CASE NO: APPEAL CASE NO: JUDGE: Court address Court telephone no. Prisoner's name, address, and inmate no. (if known) Appellant Appellee THE PEOPLE OF THE STATE OF MICHIGAN v NOTE: This form is required pursuant to MCR 7.104(D)(2)(c). If the appropriate language is included in the application for leave to appeal, this form does not need to be used. TO THE PRISONER: 1. An application for leave to appeal a decision to grant parole is being filed with the circuit court. (Attached.) 2. You are not required to respond to the attached application. If you wish to respond to the application for leave to appeal, you may respond yourself or hire an attorney to respond for you. 3. If an order of parole is issued pursuant to MCL 791.236 before the appellate proceedings are completed, a stay may be granted in the manner provided by MCR 7.105(G), except that no bond is required. TO THE PRISON/FACILITY: You are required to personally serve this notice, the application for leave to appeal, and any supporting documents on the prisoner named above. After service on the prisoner, you must complete the proof of service on the prisoner and file it with the clerk of the court. PROOF OF SERVICE I certify that on this date I served copies of this notice, the application for leave to appeal and any supporting documents by registered or certified mail, return receipt requested on the parole board, the prosecutor (if filed by victim), the victim (when appropriate), and on the facility where the prisoner is incarcerated. Date Signature of applicant/attorney Note: Attach copies of the return receipts from the parole board and the prosecutor (when filed by the victim), and the victim (when appropriate) and file a copy of this proof of service with the clerk of the court. PROOF OF SERVICE ON PRISONER I certify that on this date I personally served this notice, the application for leave to appeal, and any supporting documents on the prisoner named above. Date Signature of prison official MCL 791.234(11), MCR 7.104(D)(2) CC 404 (3/08) NOTICE TO PRISONER ON APPLICATION FOR LEAVE TO APPEAL DECISION OF PAROLE BOARD American LegalNet, Inc. www.FormsWorkflow.com