Free pca309.pmd - Michigan

Approved, SCAO

JIS CODE: CAD

STATE OF MICHIGAN
JUDICIAL CIRCUIT - FAMILY DIVISION

FILE NO. CONSENT TO ADOPTION BY AGENCY/COURT

COUNTY

In the matter of 1. I,
*Name

Full name of child

DOB: , on behalf of
*Name of agency or court

, adoptee

voluntarily consent to the adoption of the child named above by as requested in a petition on file or to be filed in court. 2. I am a representative authorized to execute this consent.
Date Signature Title

Subscribed and sworn to before me on My commission expires:
Date

Date

, in Signature:
Notary public

County, Michigan.

*The consenting party in item 1 must be one of the following: 1. A representative authorized to consent on behalf of the Michigan Department of Human Services or of a child-placing agency to whom the child has been permanently committed by an order of the family division of the circuit court. 2. The family division of the circuit court having permanent custody of the child. 3. A representative authorized to consent on behalf of the Michigan Department of Human Services or of a child-placing agency to whom the child has been released. 4. A representative authorized to consent on behalf of a child-placing agency of another state or county, which has authority to consent to the adoption. 5. An individual or official authorized by tribal law or order of the tribal court to give consent.

Do not write below this line - For court use only

PCA 309 (9/07)

CONSENT TO ADOPTION BY AGENCY/COURT

MCL 710.43, MCL 710.44, MCR 3.801