Approved, SCAO JIS CODE: PDA STATE OF MICHIGAN PROBATE COURT COUNTY OF In the matter of 1. I, Name PETITION FOR AUTHORITY TO PLACE INDIVIDUAL WITH DEVELOPMENTAL DISABILITY IN A FACILITY FILE NO. , an individual with a developmental disability , am interested in this matter and make this petition as guardian of the individual. 2. The individual is presently residing at City Address . State Zip 3. It is necessary that I be authorized by this court to admit the individual a. temporarily for a period not to exceed 30 days to Name of center located at b. to Name of center to receive clinical services. , located at for up to 10 days for a preadmission examination and subsequent administrative admission if suitable. c. to Name of facility , located at . 4. A report and evaluation required by law and court rule is filed with this petition. 5. The following are all the interested persons in this proceeding, none of which are under legal disability except as noted: NAME AGE RELATIONSHIP Street address City Street address City State Zip Telephone no. State Zip Telephone no. ADDRESS AND TELEPHONE NUMBER 6. I REQUEST that I be authorized to execute the necessary applications for the administrative admission of the individual to Name of facility . I declare under the penalties of perjury that this petition has been examined by me and that its contents are true to the best of my information, knowledge, and belief. Attorney signature Name (type or print) Address City, state, zip Telephone no. Bar no. Date Petitioner signature Address City, state, zip Telephone no. USE NOTE: If this form is being filed in the circuit court family division, please enter the court name and county in the upper left-hand corner of the form. Do not write below this line - For court use only MCL 330.1100b, MCL 330.1509, MCL 330.1510, MCL 330.1623, MCR 5.746 PC 664 (9/12) PETITION FOR AUTHORITY TO PLACE INDIVIDUAL WITH DEVELOPMENTAL DISABILITY IN A FACILITY American LegalNet, Inc. www.FormsWorkFlow.com