Approved, SCAO Original - Court 1st copy - Prisoner 2nd copy - Department of Corrections 3rd copy - Return to court STATE OF MICHIGAN JUDICIAL DISTRICT JUDICIAL CIRCUIT COUNTY PROBATE Court address CASE NO. PERSONAL SERVICE ON PRISONER AND AFFIDAVIT Court telephone no. Plaintiff(s) Defendant(s) v Probate Juvenile In the matter of REQUEST To the Warden/Administrator of You are requested to serve together with on Name of correctional institution Title or description of papers List of attachments on or before Name of prisoner and prisoner identification number (if known) . Upon service, you must either complete the affidavit of service below or have the prisoner complete the acknowledgment of service below. If you are unable to complete service for some reason, you must return the original papers and all copies to the court clerk. Date Signature Name (type or print) NOTE: This affidavit is prepared only when the prisoner does not acknowledge service. AFFIDAVIT OF SERVICE I state that I am a legally competent adult who is not a party or an officer of a corporate party, and that I personally served the papers described above and attachments, if any, on on Day, date, and time Name of prisoner and prisoner identification number (if known) . Signature Name (type or print) Subscribed and sworn to before me on Date , Signature: Deputy court clerk/Notary public County, Michigan. My commission expires: Notary public, State of Michigan, County of ACKNOWLEDGMENT OF SERVICE I acknowledge that I have received the papers described above on Day, date, time Prisoner signature MC 273 (3/13) PERSONAL SERVICE ON PRISONER AND AFFIDAVIT MCR 2.103(C), MCR 2.105, MCR 5.103(B) American LegalNet, Inc. www.FormsWorkFlow.com