Form Mmp-3050 - Request Replacement Card(S) Form - Michigan Medical Marihuana Program
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1For Official Use Only
$10 Fee Received
Michigan Medical Marihuana Program
(517) 284-6400
Request Replacement Card(s) Form
This form is for registered PATIENTS and registered CAREGIVERS who need to replace a registry identification card that was lost or stolen.
You may also change your address at this time. If a new address is listed, we'll update your address on all active registry cards. Only one
address is allowed per person in the program.
INSTRUCTIONS
1. Complete Sections A and B and include an ID for the cardholder listed in section A:
o If a Patient: Include a copy of patient’s valid Michigan driver license, personal identification card, or
signed voter registration. If a patient submits a voter registration, he or she must include additional
proof of identity for verification purposes (i.e., government-issued document that includes your
name and date of birth).
o If a Caregiver: Include copy of caregiver’s valid state-issued driver license or personal identification
card.
2. Sign and date the form.
3. Include a check or money order for $10 payable to: State of Michigan-MMMP (The $10 fee covers all
replacement cards requested).
4. Make a copy of the completed form and all required documentation for your records.
5. Do not include any other forms, fees, or documentation in the envelope.
6. Mail completed form and all required documentation in one envelope to:
Michigan Medical Marihuana Program
P.O. Box 30083
Lansing, MI 48909
Section A: Cardholder Information (As it appears on your current registry card) (REQUIRED)
Legal First Name
Legal Last Name
Suffix (Jr., Sr., etc.)
Middle Initial
Date of Birth
Telephone Number
Mailing Address (If your address has changed, provide your new address) Apartment/Suite/Lot#
State
Zip Code
City
Section B: Replace Lost/Stolen Card (REQUIRED)
*All of your active registry cards (patient and/or caregiver) will be replaced unless you identify below the specific card(s)
that you want replaced. If you made an address change all cards will be replaced.
Name on Registry Card
Name on Registry Card
Signature & Declaration (REQUIRED)
I attest the information I provided is true and accurate and that I will comply with the requirements of the Michigan Medical
Marihuana Act (Initiated Law 1 of 2008, MCL 333.26421 et seq.) and associated administrative rules. I understand that falsified or
fraudulent information may be reported to law enforcement and result in criminal prosecution.
X
Signature:
Date:
____________________________
Page 1 of 1
MMP-3050 (Rev. 9/17)
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