File No. COURT STATE OF NORTH CAROLINA COUNTY . . . . . . . . . . . .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : County In The General Court Of Justice District Court Division Index No. : Calendar No. : IN THE MATTER OF: JUDICIAL SUBPOENA Name And Address Of Respondent Plaintiff(s) -againstDrivers License No., If Known State PETITION AND CUSTODY ORDER : FOR SPECIAL EMERGENCY SUBSTANCE ABUSE : INVOLUNTARY COMMITMENT : Date Of Birth Of Respondent G.S. 122C-282 Defendant(s) : . . . . . . . .affiant,.being. first . . . . . . . . . . . . . . having. sufficient.knowledge to believe that the respondent is a proper . . . . . . . . . . . . duly sworn, and . . . . . . . . . . . . . . . . I, the undersigned subject for involuntary commitment, allege that the respondent is a resident of, or can be found in the above named county, and is a substance abuser who is dangerous to himself or others. I have taken the respondent into custody and brought the respondent immediately before the Court because he/she is violent and requires restraint and the delay which THE PEOPLE OF THE STATE OF NEW YORK would result from obtaining a medical examination would endanger life or property. TO GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Name And Address Of Nearest Relative Or Guardian (Including Zip Code) Witness, Honorable Court in County, Home Telephone No. Name And Address Of Other Person Who May Testify To Facts (Including Zip Code) , one of the Justices of the day of Business Telephone No. , 20 Home Telephone No. Business Telephone No. (Attorney must sign above and type name below) I request the Court to authorize the transportation of the respondent to a 24-hour facility for temporary custody, observation and treatment pending a district court hearing. Attorney(s) for Signature Of Petitioner-Officer SWORN AND SUBSCRIBED TO BEFORE ME Date Name And Address Of Petitioner-Officer (Including Zip Code) (Type Or Print) Office and P.O. Address Signature Deputy CSC Assistant CSC Clerk Of Superior Court Magistrate Original-File AOC-SP-909M, Rev. 9/03 2003 Administrative Office of the Courts Copy-hospital Copy-Special Counsel (Over) Telephone No.: Facsimile No.: Copy- ttorney General E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com FINDINGS COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ....... .. The Court.finds that. there are are not reasonable grounds to believe that the facts alleged in the petition : are true and that the respondent is probably a substance abuser and dangerous Index No. or others. to himself : is not in fact The Court further finds by clear, cogent, and convincing evidence that the respondent Calendar No.is violent and requires restraint, and delay in taking the respondent to a person authorized by law to conduct an examination, for examination would endanger life or property. : JUDICIAL SUBPOENA Plaintiff(s) -against- CUSTODY ORDER : TO ANY LAW ENFORCEMENT OFFICER : The Court orders you to take the named respondent into custody and transport the respondent directly to the 24-hour facility named below, for temporary custody, examination and treatment pending a district court hearing. : Defendant(s) Date : ...................................................... Name And Address of 24-Hour Facility For Substance Abuser Time AM PM Signature Deputy CSC THE PEOPLE OF THE STATE OF NEW YORK Assistant CSC Clerk Of Superior Court Magistrate RETURN OF SERVICE TO The respondent WAS NOT taken into custody for the following reason: GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , Court Date RespondentCounty of Taken Into Custody Time located at AM PM in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the I certify that this Order was received and served as follows: the the Honorable at I transported the respondent directly to and placed him in the temporary custody of the facility named below. Name Of 24-Hour Facility For Substance Abuser Date Delivered Time Date Order Received Date Of Return Your failure to comply with this subpoena is punishableEnforcement Officer of court and will make you liable to Signature Of Law as a contempt the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Name Of Transporting Agency AM Court in PM PETITIONER'S WAIVER OF NOTICE OF HEARING of the Justices of the Witness, Honorable , one County, day of , 20 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 (Attorney must sign above and type name below) Signature Of Petitioner-Officer Attorney(s) for Office and P.O. Address AOC-SP-909M, Side Two, Rev. 9/03 2003 Administrative Office of the Courts Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com