STATE OF MICHIGAN
AFFIDAVIT AND ORDER
EXCUSING RESPONDENT’S PRESENCE
In the matter of , an individual with a developmental disability
1. I am a licensed physician psychologist in the State of Michigan.
2. I examined the above named respondent on .
3. It is my professional opinion that attendance at any and all proceedings in this matter would subject the respondent to serious
risk of physical or emotional harm for the reason that:
4. I request that the respondent’s presence be excused.
Subscribed and sworn to before me on , County, Michigan.
My commission expires: Signature:
Date Deputy clerk/Register/Notary public
IT IS ORDERED that:
The Request to Excuse Respondent’s Presence is:
Judge Bar no.
Do not write below this line – For court use only
Deputy Register of Probate
PEMH 1100 (4/06) AFFIDAVIT AND ORDER EXCUSING RESPONDENT’S PRESENCE MCL 330.1617(4)