Free pca333.p65 - Michigan

Approved, SCAO

JIS CODE: FTP

STATE OF MICHIGAN
JUDICIAL CIRCUIT - FAMILY DIVISION

FILE NO. FOLLOW-UP REPORT AFTER TEMPORARY PLACEMENT OF CHILD FOR ADOPTION DOB:

COUNTY

In the matter of

Full name of child

NOTE: This report is to be completed within 30 days after the transfer of physical custody of the child. This report is in addition to the report included in the statement transferring custody (either form PCA 330 or PCA 331).

1. I am the adoption attorney the above named child. 2. On
Date

representative of the child-placing agency

that assisted in the temporary placement of

, for the purpose of adoption, physical custody of the child was transferred to the
Name(s) of prospective parent(s) Street address Name(s) of parent(s) City

prospective adoptive parent(s)

who reside(s) in
Zip

County at

.

3. The temporary placement was made by
Street address

.
City State Zip

4. Since the transfer of physical custody, the following has occurred: a. a petition for adoption was filed by the prospective adoptive parents in
Date

County on

. to
Date

b. no petition for adoption was filed and physical custody of the child was returned on ,
Name(s)

parent(s).

guardian(s).

child-placing agency.

c. neither of the above. I declare that this report has been examined by me and that its contents are true to the best of my information, knowledge, and belief.

Date Signature of adoption attorney Name (type or print) Firm name Address City, state, zip Telephone no. Bar no.

Date Signature of agency representative Name (type or print) Agency name Address City, state, zip Telephone no.

Do not write below this line - For court use only

PCA 333 (9/06)

FOLLOW-UP REPORT AFTER TEMPORARY PLACEMENT OF CHILD FOR ADOPTION

MCL 710.23d(3)