Free pca305a.pmd - Michigan


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State: Michigan
Category: Court Forms - State
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Approved, SCAO

JIS CODE: RCG

STATE OF MICHIGAN
JUDICIAL CIRCUIT - FAMILY DIVISION

FILE NO. RELEASE OF CHILD BY GUARDIAN

COUNTY

In the matter of

Full name of child

1. I,
Name

, am the court-appointed guardian for: the child named above. the parent of the child named above. at
Date Place

The child named above was born

.

2. I have authority to sign this release of the child named above for adoption by order of the Court (a copy of the order is attached and a copy of my current letters of guardianship are attached). 3. a. A judge or referee of the court, or other authorized person, has fully explained to me my legal rights as guardian and the legal rights of the parent(s) of the child named above and that I do not have to sign this release. I understand that if I do sign this release, my rights as guardian and the legal rights of each parent will be terminated. b. A judge or referee of the court, or other authorized person, has fully explained to me, as guardian of the parent, the legal rights of the parent to the child named above and that I do not have to sign this release. I understand that if I do sign this release, I voluntarily give up permanently, on behalf of the parent, his/her parental rights to the child. 4. I have not received or been promised any money or anything of value for the release of the child, except for charges and fees approved by the court. 5. I understand my rights as guardian and the rights of the parent(s) to the child and the right to request a rehearing or to appeal within 21 days after an order is entered terminating the rights of the parent(s) and of myself as guardian. 6. a. As guardian of the child named above, I voluntarily give up permanently my rights as guardian and the rights of each parent to the child named above. b. As guardian of the parent and on his/her behalf, I voluntarily give up permanently his/her parental rights to the child named above. I release the child to
Child-placing agency or Michigan Department of Human Services

for the purpose of adoption. 7. This release involves an American Indian child. The explanation given to me was in a language understood by me or interpreted into my own language if I do not speak English. This release was given more than 10 days after the birth of the child.
Guardian signature City State Zip

Date Address

See reverse side for certification by judge/referee

Do not write below this line - For court use only

PCA 305a (9/07)

RELEASE OF CHILD BY GUARDIAN

MCL 700.431(1)(c), MCL 710.28, MCL 710.29, MCL 710.54, 25 USC 1913(a), MCR 3.801

CERTIFICATION BY JUDGE/REFEREE

An investigation of this release has been made. At a hearing where a verbatim record of testimony was made, I explained to a. the guardian of the child his/her legal rights and that by signing this release, the guardian was voluntarily giving up permanently his/her rights to the child. b. the guardian of the parent the parent's legal rights and that by signing this release, the guardian was voluntarily giving up permanently, on behalf of the parent, his/her parental rights to the child. The guardian then voluntarily signed this release before me. The child named above is over five years of age, and the court finds that the child is best served by this release.

Date

Judge/Referee

Bar no.