Free pca301a.p65 - Michigan

Approved, SCAO

JIS CODE: DPA

STATE OF MICHIGAN
JUDICIAL CIRCUIT - FAMILY DIVISION

COUNTY

PETITION FOR DIRECT PLACEMENT ADOPTION

FILE NO.

In the matter of

Full name of child

, adoptee
Relationship to Adoptee Date and Place of Birth

The petitioners are:
Name Address, City, State, Zip

Adopting Mother
Maiden:

Adopting Father Each adopting petitioner states: 1. An action within the jurisdiction of the family division of circuit court involving the family or family members of the minor has been previously filed in assigned to Judge 2. The adoptee was born on
Birth date and time

Court, Case Number , and at
City, county, and state of birth

, was remains is no longer pending. . by a parent/guardian. child-placing agency.

3. The adoptee was temporarily placed in my home on 4. The adoptee will be my heir at law. not be changed. 5. The adoptee's name will be changed to 6. The adoptee's property is

Date

First

Middle

Last

. .

7. The parties to this adoption have elected not to exchange identifying information. A separate verified statement of the identifying information is attached. NOTE: Do not complete items 8. and 9. if item 7. is checked. 8. The adoptee is:
Full name of child Present residential address (if known)

The adoptee's parents are:
Father's name Address City, state, zip Birth date Mother's name (and maiden name) Address City, state, zip Birth date

(PLEASE SEE OTHER SIDE)
Do not write below this line - For court use only

PCA 301a (3/06)

PETITION FOR DIRECT PLACEMENT ADOPTION

MCL 710.24, MCL 710.46, MCL 710.56

9. The adoptee's court-appointed guardian and/or conservator is/are

Name(s) and address(es)

. 10. I have received a copy of the reasonably obtainable nonidentifying information required for a placement of the child for adoption. A copy is attached. 11. I have been informed of the availability of counseling services. I have have not received counseling.

12. No preplacement assessments have been completed on us other than those attached. Preplacement assessments have been started but not completed as follows:

I REQUEST: 13. Termination of all existing parental rights inconsistent with the order of adoption, entry of an order approving placement of the child with me, and entry of an order of adoption with the adoptee's name recorded as: . 14. The adoption be completed immediately because:

15. The court to waive the required investigation because the adoptee has been placed in foster care with me for at least 12 months and a foster family study was completed or updated within the last 12 months. 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.
Attorney/Agency signature Attorney/Agency name (type or print) Address City, state, zip Telephone no. Bar no. Date Signature of petitioner mother Signature of petitioner father Petitioner telephone no.

IT IS ORDERED: 16. The preplacement assessment filed with the petition has been reviewed by the court and a. it is a sufficient investigation of the adoptive home, and no further investigation is required. b.
Court agent or employee, child-placing agency

is directed to conduct an additional investigation and report its findings in writing to this court, within 3 months of this order, in accordance with the provisions of section 46 of the Michigan Adoption Code. 17. The full investigation is waived. The petitioner(s) shall file a copy of the most recent foster family study as updated and supplemented.
Date Judge Bar no.