Free pca306.p65 - Michigan

Approved, SCAO

JIS CODE: RAG

STATE OF MICHIGAN
JUDICIAL CIRCUIT - FAMILY DIVISION

FILE NO. RELEASE OF CHILD BY CHILD PLACING AGENCY DOB: , adoptee

COUNTY In the matter of
Full name of child

I,

Name of representative

, on behalf of

Name of child placing agency

voluntarily release and relinquish parental rights to the child named above to the Michigan Department of Human Services for the purpose of adoption or suitable placement. I am the duly authorized representative of the child placing agency.
Signature Title

Subscribed and sworn to before me on My commission expires:
Date

Date

in Signature:
Notary public

County, Michigan.

Notary public, State of Michigan, County of

Do not write below this line - For court use only

PCA 306 (11/05)

RELEASE OF CHILD BY CHILD PLACING AGENCY

MCL 710.28, MCL 710.29, MCR 3.801