Free pca342.pmd - Michigan

Approved, SCAO

JIS CODE: ACI

STATE OF MICHIGAN
JUDICIAL CIRCUIT - FAMILY DIVISION

FILE NO. PETITION AND ORDER TO APPOINT CONFIDENTIAL INTERMEDIARY

COUNTY

In the matter of

Full name of child

, adoptee PETITION

1. I am an

adult adoptee. adoptive parent of the adoptee who is a minor. adult child of the deceased adoptee whose date of death is
Date

.

I REQUEST the court to appoint a confidential intermediary to search for and contact a former family member of mine who is believed to be my mother. father. grandparent. adult sibling. 2. I am a former family member of the adoptee. I am the adoptee's parent. grandparent. adult sibling. I REQUEST the court to appoint a confidential intermediary to search for and contact the adult adoptee. an adult child of the deceased adoptee whose date of death is

Date

.

I declare that this petition has been examined by me and that its contents are true to the best of my information, knowledge, and belief.
Date Signature of petitioner Name of petitioner (type or print) Address City, state, zip Telephone no.

ORDER 3. Date of hearing: 4.
Name (type or print)

Judge:
Bar no.

is appointed confidential intermediary to search for and

the former mother. the former father. the former grandparent. the adult adoptee. an adult child of the deceased adoptee. adult sibling. The confidential intermediary shall file with the court within 6 months of this order a written report of the intermediary's efforts to search for and contact the individual and any results. The confidential intermediary shall have access to the adoptee's court file and records. 5. The former mother former father has on file with the central adoption registry a denial of consent to the release of identifying information. The petition to search for that former parent is denied.

contact

Date

Judge

Do not write below this line - For court use only

PCA 342 (9/07)

PETITION AND ORDER TO APPOINT CONFIDENTIAL INTERMEDIARY

MCL 710.68b