THE PEOPLE OF

 The State of Michigan

 
 

NOTE: This form is required under MCR 7.118(D)(3)(b). 

TO THE PRISONER:

Prisoner’s name, address, and inmate no. (if known) 

 

 

 

   Appellee

v

1. An application for leave to appeal a decision to grant parole is being filed with the circuit court.  (Copy attached.)

2. You are not required to respond to the attached application.  If you wish to respond to the application for leave to  
 
  appeal, you may respond yourself, hire an attorney to respond for you, or request a court-appointed attorney if you are 
 

financially unable to hire one.

3. If an order of parole is issued under MCL 791.236 before the appellate proceedings are completed, a stay may be  
  granted in the manner provided by MCR 7.118(F), except that no bond is required.

 

TO THE PRISON/FACILITY: You are required to personally serve this notice, the application for leave to appeal, and any 
supporting documents on the prisoner named above. After service on the prisoner, you must complete the proof of service 
on the prisoner and file it with the clerk of the court.

I declare under the penalties of perjury that on this date I served copies of this notice, the application for leave to appeal 
and any supporting documents by registered or certified mail, return receipt requested on the parole board, the prosecutor 
(if filed by victim), the victim (when appropriate), and on the facility where the prisoner is incarcerated. 

PROOF OF SERVICE

Date

Signature of applicant/attorney 

 

 

 

Note: Attach copies of the return receipts from the parole board and the prosecutor (when filed by the victim) and from the 
victim (when appropriate), and file a copy of this proof of service with the clerk of the court.

I declare under the penalties of perjury that on this date I personally served this notice, the application for leave to appeal, 
and any supporting documents on the prisoner named above.

PROOF OF SERVICE ON PRISONER

Date

Signature of prison official 

 

 

 

STATE OF MICHIGANJUDICIAL CIRCUITCOUNTY NOTICE TO PRISONER ON APPLICATION FOR LEAVE TO APPEAL DECISION OF PAROLE BOARDCIRCUIT CASE NO:APPEAL CASE NO:JUDGE:Court addressCourt telephone no.Approved, SCAOForm CC 404, Rev. 4/21MCL 791.234(11), MCR 7.118(D)(3)Page 1 of 1Distribute form to:PrisonerParole boardProsecutor/VictimPrison/FacilityCourt (for proof from prison/facility)Court (for proof from prosecutor/victim)Appellant