File No. STATE OF NORTH CAROLINA In The General Court Of Justice County District Court Division IN THE MATTER OF: Name Of Respondent REQUEST AND AUTHORIZATION TO DELIVER RESPONDENT G.S. 122C-251(f) REQUEST I request that I be authorized to transport the above named respondent to the mental health facility named below, and agree to bear the cost of such transportation. I believe the respondent is not substantially dangerous to himself/herself or others. Date Signature Of Person Making Request AUTHORIZATION Under North Carolina law, and upon request, the individual named below is authorized and directed to immediately transport and deliver the respondent to the facility named below. Name And Address Of Person Authorized To Transport And Deliver RespondentName And Address Of Mental Health Facility You are also directed to deliver the court records pertaining to respondents admission to the admitting official of the facility, and obtain an acknowledgment of your delivery of the respondent and the court records from the admitting official of the facility. The acknowledgment of delivery shall be immediately returned to the Clerk. Date Signature Magistrate Deputy CSC Assistant CSC CSC ACKNOWLEDGMENT BY MENTAL HEALTH FACILITY I acknowledge receipt of respondent and copies of the court records relating to admission of the respondent at this facility. I understand that under North Carolina law the findings of the physician must be returned to the Clerk within forty-eight (48) hours. Name Of Facility Date Signature Title AOC-SP-902M, Rev. 7/95 1997 Administrative Office of the Courts Original-File Copy-Hospital