STATE OF NORTH CAROLINA County Name And Address Of Respondent File No. In The General Court Of Justice District Court Division IN THE MATTER OF: AFFIDAVIT AND PETITION FOR INVOLUNTARY COMMITMENT Drivers License No. Of Respondent State G.S. 122C-261, 122C-281 Date Of Birth I, the undersigned affiant, being first duly sworn, and having sufficient knowledge to believe that the respondent is a proper subject for involuntary commitment, allege that the respondent is a resident of, or can be found in the above named county, and is: (Check all that apply) 1. mentally ill and dangerous to self or others or mentally ill and in need of treatment in order to prevent further disability or deterioration that would predictably result in dangerousness. in addition to being mentally ill, respondent is also mentally retarded. 2. a substance abuser and dangerous to self or others. The facts upon which this opinion is based are as follows: (State facts, not conclusions, to support ALL blocks checked.) Name And Address Of Nearest Relative Or Guardian Name And Address Of Person Other Than Petitioner Who May Testify Home Telephone No. Business Telephone No. Home Telephone No. Business Telephone No. Petitioner requests the court to issue an order to a law enforcement officer to take the respondent into custody for examination by a person authorized by law to conduct the examination for the purpose of determining if the respondent should be involuntarily committed. SWORN/AFFIRM AND SUBSCRIBED TO BEFORE ME Date Signature Signature Of Petitioner Name And Address Of Petitioner (Type Or Print) Deputy CSC Assistant CSC Clerk Of Superior Court Date Notary Commission Expires County Where Notarized Magistrate Relationship To Respondent Home Telephone No. Business Telephone No. Notary (use only with physician or psychologist petitioner) SEAL AOC-SP-300, Rev. 7/11 © 2011 Administrative Office of the Courts Original-File Copy-Hospital Copy-Special Counsel Copy-Attorney General (Over) PETITIONER'S WAIVER OF NOTICE OF HEARING I voluntarily waive my right to notice of all hearings and rehearings in which the Court may commit the respondent or extend the respondent's commitment period, or discharge the respondent from the treatment facility. Signature Of Witness Date Signature Of Petitioner NOTE: "Upon the request of the legally responsible person or the minor admitted or committed, and after that minor has both been released and reached adulthood, the court records of that minor made in proceedings pursuant to Article 5 of [Chapter 122C] may be expunged from the files of the court." G.S. 122C-54(e) AOC-SP-300, Side Two, Rev. 7/11 © 2011 Administrative Office of the Courts