Approved, SCAO
Original - Court Copy - Secretary of Interior
STATE OF MICHIGAN
JUDICIAL CIRCUIT - FAMILY DIVISION
CASE NO. CERTIFICATE OF ADOPTIVE INFORMATION
COUNTY
1. In the matter of
(name(s), alias(es), DOB)
2. The tribal affiliation of the child is 3. The names and addresses of the natural parents of the child are:
Name of natural father (type or print) Address City, state, and zip
.
Name of natural mother (type or print) Address City, state, and zip
4. The names and addresses of the adoptive parents of the child are:
Name of adoptive father (type or print) Address City, state, and zip
Name of adoptive mother (type or print) Address City, state, and zip
5. The name of the agency having information pertaining to the adoption is .
Date Signature
Do not write below this line - For court use only
PCA 328 (9/97)
CERTIFICATE OF ADOPTIVE INFORMATION
25 USC 1951