Form PC664 "Petition for Authority to Place Individual With Developmental Disability in a Facility" - Michigan

What Is Form PC664?

This is a legal form that was released by the Michigan Probate Court - a government authority operating within Michigan. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2012;
  • The latest edition provided by the Michigan Probate Court;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form PC664 by clicking the link below or browse more documents and templates provided by the Michigan Probate Court.

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Download Form PC664 "Petition for Authority to Place Individual With Developmental Disability in a Facility" - Michigan

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Approved, SCAO
JIS CODE: PDA
STATE OF MICHIGAN
FILE NO.
PETITION FOR AUTHORITY TO PLACE
PROBATE COURT
INDIVIDUAL WITH DEVELOPMENTAL
COUNTY OF
DISABILITY IN A FACILITY
In the matter of
, an individual with a developmental disability
1.
I,
, am interested in this matter and make this petition as guardian of
Name
the individual.
2.
The individual is presently residing at
Address
.
City
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
to receive clinical services.
b. to
, located at
Name of center
for up to 10 days for a preadmission examination and subsequent administrative admission if suitable.
c. to
, located at
.
Name of facility
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
ADDRESS AND TELEPHONE NUMBER
Street address
City
State
Zip
Telephone no.
Street address
City
Telephone no.
State
Zip
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
Date
Name (type or print)
Petitioner signature
Bar no.
Address
Address
City, state, zip
City, state, zip
Telephone no.
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
PETITION FOR AUTHORITY TO PLACE INDIVIDUAL WITH DEVELOPMENTAL DISABILITY IN A FACILITY
PC 664 (9/12)
Approved, SCAO
JIS CODE: PDA
STATE OF MICHIGAN
FILE NO.
PETITION FOR AUTHORITY TO PLACE
PROBATE COURT
INDIVIDUAL WITH DEVELOPMENTAL
COUNTY OF
DISABILITY IN A FACILITY
In the matter of
, an individual with a developmental disability
1.
I,
, am interested in this matter and make this petition as guardian of
Name
the individual.
2.
The individual is presently residing at
Address
.
City
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
to receive clinical services.
b. to
, located at
Name of center
for up to 10 days for a preadmission examination and subsequent administrative admission if suitable.
c. to
, located at
.
Name of facility
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
ADDRESS AND TELEPHONE NUMBER
Street address
City
State
Zip
Telephone no.
Street address
City
Telephone no.
State
Zip
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
Date
Name (type or print)
Petitioner signature
Bar no.
Address
Address
City, state, zip
City, state, zip
Telephone no.
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
PETITION FOR AUTHORITY TO PLACE INDIVIDUAL WITH DEVELOPMENTAL DISABILITY IN A FACILITY
PC 664 (9/12)