Petition For Involuntary Commitment - North Dakota Page 3

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North Dakota Supreme Court

SFN 17260 (GN-1) (Rev. 08-2015)

Page 3

State of North Dakota

)

) ss.

County of ________________________)

The undersigned, being first sworn, on their oath states that the undersigned is the petitioner in the above matter, and that the facts in this petition are true to

the affiant's best information and belief

X___________________________________________________________

Petitioner

Dated this ________ day of ____________________ of ________, before me personally appeared ______________________________________________

______________________________________________ who having been sworn state that to the best of their knowledge and belief the statements in this

petition are true.

X___________________________________________________________

Notary Public

(Seal)

My commission expires

__________________________________________

APPROVAL OF ATTORNEY