Form MMP-3051 "Add or Change Caregiver Amendment" - Michigan

What Is Form MMP-3051?

This is a legal form that was released by the Michigan Department of Environment, Great Lakes, and Energy - 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 October 1, 2019;
  • The latest edition provided by the Michigan Department of Environment, Great Lakes, and Energy;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form MMP-3051 by clicking the link below or browse more documents and templates provided by the Michigan Department of Environment, Great Lakes, and Energy.

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Download Form MMP-3051 "Add or Change Caregiver Amendment" - Michigan

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For Official Use Only
Michigan Medical Marijuana Program
www.michigan.gov/mmp
(517) 284-6400
Add or Change Caregiver Amendment
This form is for active registered PATIENTS who are adding or changing their caregiver. You may also change your address at this time. If a
new address is listed, we'll update your address on all active registry cards. Only one address is allowed per person in the program.
INSTRUCTIONS
1. Complete Sections A, B, and C and include the following:
o Patient: Include a copy of patient’s valid Michigan driver license, personal identification card, or signed
voter registration. If a patient submits a voter registration, he or she must include additional proof of
identity for verification purposes (i.e., government-issued document that includes your name and date
of birth).
o Caregiver: Include copy of new caregiver’s valid state-issued driver license or personal identification cards.
The form must be signed and dated within 6 months of being received.
2.
Make a copy of the completed form and all required documentation for your records.
3.
Do not include any other forms, fees, or documentation in the envelope.
4.
Mail completed form and all required documentation in one envelope to:
5.
Michigan Medical Marijuana Program
P.O. Box 30083
Lansing, MI 48909
Section A: Patient Information (As it appears on your current registry ID card) (REQUIRED)
Patient Registry ID Card Number (If known)
Date of Birth
Telephone Number
Legal First Name
Middle Initial
Legal Last Name
Suffix (Jr., Sr., etc.)
Mailing Address
Apartment/Suite/Lot #
(If your address has changed, provide your new address)
State
City
Zip Code
Section B: New Caregiver Information (REQUIRED)
Middle Initial
Suffix (Jr., Sr., etc.)
Legal First Name
Legal Last Name
Date of Birth
Aliases/Maiden Name
Mailing Address
Apartment/Suite/Lot #
City
State
Zip Code
Section C: Plant Possession (REQUIRED)
Plant possession: You must select one box. Select Only One:
I will possess the plants
My caregiver will possess the plants
Patient Signature & Declaration (REQUIRED)
I attest the information I provided is true and accurate and that I will comply with the requirements of the Michigan Medical Marihuana Act (Initiated
Law 1 of 2008, MCL 333.26421 et seq.) and associated administrative rules. I understand that falsified or fraudulent information may be reported to law
enforcement and result in criminal prosecution.
X
Signature of Patient:
Date:
___________________________
Caregiver Signature & Declaration (REQUIRED)
I attest the information I provided is true and accurate and that I will comply with the requirements of the Michigan Medical Marihuana Act (Initiated
Law 1 of 2008, MCL 333.26421 et seq.) and associated administrative rules. Further, I agree to serve as the patient’s primary caregiver, have no
convictions that will disqualify me from serving as a primary caregiver, and authorize the department to use the information provided to perform a
criminal background check. I understand that falsified or fraudulent information may be reported to law enforcement and result in criminal
prosecution.
X
Signature of Caregiver:
Date:
____________________________
MMP-3051 (Rev. 10/19)
Page 1 of 1
For Official Use Only
Michigan Medical Marijuana Program
www.michigan.gov/mmp
(517) 284-6400
Add or Change Caregiver Amendment
This form is for active registered PATIENTS who are adding or changing their caregiver. You may also change your address at this time. If a
new address is listed, we'll update your address on all active registry cards. Only one address is allowed per person in the program.
INSTRUCTIONS
1. Complete Sections A, B, and C and include the following:
o Patient: Include a copy of patient’s valid Michigan driver license, personal identification card, or signed
voter registration. If a patient submits a voter registration, he or she must include additional proof of
identity for verification purposes (i.e., government-issued document that includes your name and date
of birth).
o Caregiver: Include copy of new caregiver’s valid state-issued driver license or personal identification cards.
The form must be signed and dated within 6 months of being received.
2.
Make a copy of the completed form and all required documentation for your records.
3.
Do not include any other forms, fees, or documentation in the envelope.
4.
Mail completed form and all required documentation in one envelope to:
5.
Michigan Medical Marijuana Program
P.O. Box 30083
Lansing, MI 48909
Section A: Patient Information (As it appears on your current registry ID card) (REQUIRED)
Patient Registry ID Card Number (If known)
Date of Birth
Telephone Number
Legal First Name
Middle Initial
Legal Last Name
Suffix (Jr., Sr., etc.)
Mailing Address
Apartment/Suite/Lot #
(If your address has changed, provide your new address)
State
City
Zip Code
Section B: New Caregiver Information (REQUIRED)
Middle Initial
Suffix (Jr., Sr., etc.)
Legal First Name
Legal Last Name
Date of Birth
Aliases/Maiden Name
Mailing Address
Apartment/Suite/Lot #
City
State
Zip Code
Section C: Plant Possession (REQUIRED)
Plant possession: You must select one box. Select Only One:
I will possess the plants
My caregiver will possess the plants
Patient Signature & Declaration (REQUIRED)
I attest the information I provided is true and accurate and that I will comply with the requirements of the Michigan Medical Marihuana Act (Initiated
Law 1 of 2008, MCL 333.26421 et seq.) and associated administrative rules. I understand that falsified or fraudulent information may be reported to law
enforcement and result in criminal prosecution.
X
Signature of Patient:
Date:
___________________________
Caregiver Signature & Declaration (REQUIRED)
I attest the information I provided is true and accurate and that I will comply with the requirements of the Michigan Medical Marihuana Act (Initiated
Law 1 of 2008, MCL 333.26421 et seq.) and associated administrative rules. Further, I agree to serve as the patient’s primary caregiver, have no
convictions that will disqualify me from serving as a primary caregiver, and authorize the department to use the information provided to perform a
criminal background check. I understand that falsified or fraudulent information may be reported to law enforcement and result in criminal
prosecution.
X
Signature of Caregiver:
Date:
____________________________
MMP-3051 (Rev. 10/19)
Page 1 of 1