Free pca310.pmd - Michigan

Approved, SCAO

JIS CODE: PHT

STATE OF MICHIGAN
JUDICIAL CIRCUIT - FAMILY DIVISION

COUNTY

PETITION FOR HEARING TO IDENTIFY FATHER AND DETERMINE OR TERMINATE HIS RIGHTS

FILE NO.

In the matter of
Full name of child

, adoptee
Date

1. I am the mother of the adoptee named above who was born out of wedlock on

at . The adoptee resides at

City, county, and state

.
Address City State Zip

2. 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 3. I plan to sign a release consent Court, Case Number , and remains is no longer , was pending.

giving up my parental rights to the child.

4. I have joined with my husband in a petition for adoption. 5. The putative father of my child is
Address Name (type or print) City Birthdate (if unknown, state if over 18 years old)

.
State Name (type or print) Zip

6. For part or all of the time from conception to the date the child was born, I was married to whose last-known address is

. He is not the father of the child. 7. I request the court to hold a hearing to determine the identity of the father of my child and to determine or terminate his parental rights. 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 Attorney signature Attorney name (type or print) Address City, state, zip Telephone no. Bar no. Signature of petitioner Name (type or print) Address City, state, zip Telephone no.

Do not write below this line - For court use only

MCL 710.22(d), MCL 710.36, MCR 3.801, MCR 3.803 PCA 310 (9/07)

PETITION FOR HEARING TO IDENTIFY FATHER AND DETERMINE OR TERMINATE HIS RIGHTS