Approved, SCAO JIS CODE: NO/CSP FILE NO. STATE OF MICHIGAN PROBATE COURT COUNTY NOTICE OF HOSPITALIZATION AND CERTIFICATE OF SERVICE CIRCUIT COURT - FAMILY DIVISION In the matter of NOTICE TO THE PROBATE COURT: Attached is an application for hospitalization and two clinical certificates. You are notified that: 1. The individual named above was hospitalized on at Date . Time 2. The clinical certificate of the psychiatrist that is required for hospitalization was completed on Date at . Time CERTIFICATE OF SERVICE ON PATIENT 3. I certify that on the dates and times indicated a copy of each of the following documents was given to the individual named above. a. Application/Petition Date Time Signature Date Time Signature Date Time Signature Date Time Signature Date Time Signature b. Statement explaining individual's rights c. Clinical certificate of psychiatrist d. Clinical certificate of licensed psychologist/ physician/psychiatrist e. Notice of hearing CERTIFICATE OF SERVICE ON OTHERS 4. I certify that copies of the application/petition, two clinical certificates, statement explaining rights, and notice of hearing were by first-class mail served personally on on Date and time Individual's by first-class mail personally on and guardian nearest relative on Date and time Individual's attorney 5. I further certify that the individual was asked if s/he desired that other persons be served with copies of these documents, and the individual designated . Name(s) a. Copies were served on them on __________________________ by mail. personally. Date b. Service was not made because the person(s) could not be located. Date Signature Do not write below this line - For court use only MCL 330.1430, MCL 330.1431, MCL 330.1448, MCL 330.1449 PCM 211 (9/07) NOTICE OF HOSPITALIZATION AND CERTIFICATE OF SERVICE American LegalNet, Inc. www.FormsWorkflow.com