Free mc67.pmd - Michigan

Approved, SCAO

Original - Court 1st copy - Claimant

2nd copy - Defendant 3rd copy - Prosecuting official

STATE OF MICHIGAN JUDICIAL DISTRICT JUDICIAL CIRCUIT COUNTY
ORI

CASE NO. CLAIM OF INTEREST ON VEHICLE SEIZED FOR FORFEITURE
Court telephone no.

Court address

MI-

The State of Michigan THE PEOPLE OF v

Defendant's name, address, and telephone no.

CTN

SID

DOB

1. I

own lease hold security interest in Vehicle description:
Year Make Model

the following vehicle, which was seized for forfeiture as a sanction against the defendant.

License plate no.

Vehicle identification no.

2. Attached is a copy of my

title for the vehicle lease for the vehicle. proof of security interest in the vehicle.

3. My interest in the vehicle is as follows:

4. I request a hearing to determine the legitimacy of my claim, my equity interest in the vehicle, and the defendant's liability to me.

Date

Signature Name (type or print) Address City, state, zip Telephone no.

MC 67 (3/08)

CLAIM OF INTEREST ON VEHICLE SEIZED FOR FORFEITURE

MCL 257.625n(6)