Approved, SCAO

STATE OF MICHIGAN
JUDICIAL CIRCUIT COURT
COUNTY

In the matter of

1. I believe

Name (type or print)

AFFIDAVIT TO ACCOMPANY
PETITION FOR TRANSPORT AND/OR
TEMPORARY DETENTION

CASE NO.

specify infectious agent or serious communicable disease or infection

    to be a carrier of

        because of the following facts:

2. I believe the individual is a health threat to others because of the following facts:

3. The individual requires the following services at an emergency care or treatment facility:

4. An emergency order is necessary because of the following facts:

Date

Affiant's signature

Name (type or print)

Address

City, state, zip

Telephone no.

Subscribed and sworn to before me on

    ,

  County, Michigan.

My commission expires:

      Signature:

Date

Notary public

Date

Do not write below this line - For court use only

PC 109   (6/98)   AFFIDAVIT TO ACCOMPANY PETITION FOR TRANSPORT AND/OR TEMPORARY DETENTION

MCL 333.5207(1),(2); MSA  14.15(5207)(1), (2), MCR 5.782



Affidavit to Accompany Petition for Transport and/or Temporary Detention

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the Michigan state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

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About This Form:

• Sourced from www.courts.michigan.gov/commitment-testing-ID (2023-03)
• Page(s): 1
• Fields(s): 19
• Average fields per page: 19
• Reading Level: Grade 9
• LIST Grouping(s): HE-00-00-00-00.

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