Approved, SCAO STATE OF MICHIGAN AFFIDAVIT TO ACCOMPANY CASE NO. JUDICIAL CIRCUIT COURT PETITION FOR TRANSPORT AND/OR COUNTY TEMPORARY DETENTION In the matter of 1. I believe to be a carrier of Name (type or print) because of the following facts: specify infectious agent or serious communicable disease or infection 2. I believe the individual is a health threat to others because of the following facts: 3. The individual requires the following services at an emergency care or treatment facility: 4. An emergency order is necessary because of the following facts: Date Affiants signature Address Name (type or print) City, state, zip Telephone no.Subscribed and sworn to before me on Date , County, Michigan.My commission expires: Signature: Date Notary public Do not write below this line - For court use only MCL 333.5207(1),(2); MSA 14.15(5207)(1), (2), MCR 5.782PC 109 (6/98) AFFIDAVIT TO ACCOMPANY PETITION FOR TRANSPORT AND/OR TEMPORARY DETENTION