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PC 664 (9/12) PETITION FOR AUTHORITY TO PLACE INDIVIDUAL WITH DEVELOPMENTAL DISABILITY IN A FACILITY In the matter ofFILE NO. PETITION FOR AUTHORITY TO PLACE INDIVIDUAL WITH DEVELOPMENTAL DISABILITY IN A FACILITY MCL 330.1100b, MCL 330.1509, MCL 330.1510, MCL 330.1623, MCR 5.746 , an individual with a developmental disability 1. 2. 3.I, , am interested in this matter and make this petition as guardian of the individual. The individual is presently residing at . It is necessary that I be authorized by this court to admit the individual a. temporarily for a period not to exceed 30 days to located atto receive clinical services. b. to , located at for up to 10 days for a preadmission examination and subsequent administrative admission if suitable. c. to , located at . Name of facility ADDRESS AND TELEPHONE NUMBER RELATIONSHIP NAME AGE The following are all the interested persons in this proceeding, none of which are under legal disability except as noted: A report and evaluation required by law and court rule is filed with this petition. 4. 5. 6. I REQUEST that I be authorized to execute the necessary applications for the administrative admission of the individual to . 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. Telephone no. Telephone no. Attorney signature Name (type or print) Address City, state, zipAddress Petitioner signature City, state, zip Date Do not write below this line - For court use only Address Name CityState Zip Name of center Name of center Name of facility Bar no. JIS CODE: PDA Approved, SCAO STATE OF MICHIGAN PROBATE COURT COUNTY OF 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. Street address City State Zip Telephone no. Street address City State Zip Telephone no.