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File No. STATE OF NORTH CAROLINA In The General Court Of Justice District Court Division County IN THE MATTER OF Name Address And Zip Code Of Respondent AFFIDAVIT AND PETITION FOR INVOLUNTARY COMMITMENT G.S. 122C-261 122C-281 Drivers License No. Of Respondent Date Of Birth Social Security No. Of Respondent State I the undersigned affiant being first duly sworn and having sufficient knowledge to believe that the respondent is a proper subject for involuntary commitment allege that the respondent is a resident of or can be found in the above named county and is Check all that apply 1. mentally ill and dangerous to self or others or mentally ill and in need of treatment in order to prevent further disability or deterioration that would predictably result in dangerousness. in addition to being mentally ill respondent is also mentally retarded* 2. a substance abuser and dangerous to self or others. The facts upon which this opinion is based are as follows State facts not conclusions to support ALL blocks checked* Home Telephone No* Business Telephone No* Petitioner requests the court to issue an order to a law enforcement officer to take the respondent into custody for examination by a person authorized by law to conduct the examination for the purpose of determining if the respondent should be involuntarily committed* Signature Of Petitioner SWORN AND SUBSCRIBED TO BEFORE ME Date Signature Deputy CSC Assistant CSC Clerk Of Superior Court Notary use only with physician or psychologist petitioner Date Notary Commission Expires Magistrate Relationship To Respondent SEAL AOC-SP-300 Rev* 9/03 2003 Administrative Office of the Courts Original-File Copy-Hospital Copy-Special Counsel Copy-Attorney General Over PETITIONER S WAIVER OF NOTICE OF HEARING I voluntarily waive my right to notice of all hearings and rehearings in which the Court may commit the respondent or extend the respondent s commitment period or discharge the respondent from the treatment facility. mentally ill and dangerous to self or others or mentally ill and in need of treatment in order to prevent further disability or deterioration that would predictably result in dangerousness. in addition to being mentally ill respondent is also mentally retarded* 2. a substance abuser and dangerous to self or others. in addition to being mentally ill respondent is also mentally retarded* 2. a substance abuser and dangerous to self or others. The facts upon which this opinion is based are as follows State facts not conclusions to support ALL blocks checked* Home Telephone No* Business Telephone No* Petitioner requests the court to issue an order to a law enforcement officer to take the respondent into custody for examination by a person authorized by law to conduct the examination for the purpose of determining if the respondent should be involuntarily committed* Signature Of Petitioner SWORN AND SUBSCRIBED TO BEFORE ME Date Signature Deputy CSC Assistant CSC Clerk Of Superior Court Notary use only with physician or psychologist petitioner Date Notary Commission Expires Magistrate Relationship To Respondent SEAL AOC-SP-300 Rev* 9/03 2003 Administrative Office of the Courts Original-File Copy-Hospital Copy-Special Counsel Copy-Attorney General Over PETITIONER S WAIVER OF NOTICE OF HEARING I voluntarily waive my right to notice of all hearings and rehearings in which the Court may commit the respondent or extend the respondent s commitment period or discharge the respondent from the treatment facility.