In the matter of 

First, middle, and last name

1. I, 

 Name (type or print)

 , state that I am

 

 a resident 

 a person acting on behalf of a resident in 

 .

2. I object to the conclusion(s) in the periodic review report of 

 Name of facility

 Name of resident

  dated 

 

 and filed with this court. The individual named in that report does not meet the criteria

 

for judicially ordered treatment as prescribed by MCL 330.1531(3).

3. The interested parties, their addresses, and their representatives are identical to those appearing on the initial petition,
  except as follows:

4. I REQUEST that the court set a hearing and order a discharge.

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.

Date

 

Signature of petitioner

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 onlyPCM 220a (2/19) PETITION FOR DISCHARGE FROM JUDICIAL ADMISSIONMCL 330.1531Approved, SCAO JIS CODE: PDJSTATE OF MICHIGANPROBATE COURTCOUNTY OFPETITION FOR DISCHARGEFROM JUDICIAL ADMISSIONFILE NO.

PCM 220a, Petition for Discharge From Judicial Admission

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• Sourced from www.courts.michigan.gov/MH-Forms (2023-03)
• Page(s): 1
• Fields(s): 12
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• Reading Level: Grade 10
• LIST Grouping(s): CO-00-00-00-00, CO-07-00-00-00.

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