Free pca313.pmd - Michigan

Approved, SCAO

JIS CODE: DNR

STATE OF MICHIGAN
JUDICIAL CIRCUIT - FAMILY DIVISION

FILE NO. PETITION TO ISSUE NOTICE OF INTENT TO RELEASE OR CONSENT

COUNTY

In the matter of

Petitioner

1. I am pregnant out of wedlock and intend to release the expected child for adoption or to consent to the child's adoption. 2. The approximate date of conception was
Location, including city, county, and state Date

at the following location:

3. The name and address of the putative father of my expected child is *
Address City

Name (type or print)

.
State Zip

4. I request the court to notify the putative father about his rights to file a notice of intent to claim paternity by issuing and serving upon him a notice of intent to release or consent.

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.

*The petition may include more than one putative father where circumstances warrant it.

Do not write below this line - For court use only

PCA 313 (9/07)

PETITION TO ISSUE NOTICE OF INTENT TO RELEASE OR CONSENT

MCL 710.33, MCL 710.34, MCR 3.801