Original - Court
1st copy - Prisoner
2nd copy - Department of Corrections
3rd copy - Return to court

CASE NO.

Court  telephone  no.

Approved,  SCAO

STATE OF MICHIGAN

JUDICIAL DISTRICT
JUDICIAL CIRCUIT
COUNTY PROBATE

Court  address

Plaintiff(s)

PERSONAL SERVICE
ON PRISONER AND AFFIDAVIT

Defendant(s)

v

Probate

Juvenile

 In the matter of

REQUEST

To the Warden/Administrator of

Name of correctional institution

You are requested to serve

Title or description of papers

together with

List of attachments

Name of prisoner and prisoner identification number (if known)

Upon service, you must either complete the affidavit of service below or have the prisoner complete the acknowledgment of service
below. If you are unable to complete service for some reason, you must return the original papers and all copies to the court clerk.

on or before

    .

on

Date

NOTE:  This affidavit is prepared only when the
prisoner  does  not  acknowledge  service.

AFFIDAVIT OF SERVICE

I state that I am a legally competent adult who is not a party or an officer of a corporate party, and that I personally served the papers

described above and attachments, if any, on

Name of prisoner and prisoner identification number (if known)

on

Day, date, and time

.

Signature

Name (type or print)

Signature

Name (type or print)

     ,

Subscribed and sworn to before me on

Date

  County, Michigan.

My commission expires:

Signature:

Deputy court clerk/Notary public

Notary public, State of Michigan, County of

I acknowledge that I have received the papers described above on

Day, date, time

ACKNOWLEDGMENT OF SERVICE

Prisoner  signature

MC 273   (3/13)   PERSONAL SERVICE ON PRISONER AND AFFIDAVIT

MCR 2.103(C), MCR 2.105, MCR 5.103(B)