Free pca305.p65 - Michigan

Approved, SCAO

JIS CODE: RCP

STATE OF MICHIGAN
JUDICIAL CIRCUIT - FAMILY DIVISION

FILE NO. RELEASE OF CHILD BY PARENT

COUNTY

In the matter of
Full name of child

1. I,
Name

, am the at
Date Place

mother father

(Date of birth (Date of birth

) ) .

of the child named above, who was born

2. A judge or referee of the court, or other authorized person, has fully explained to me my legal rights as a parent and that I do not have to sign this release of my parental rights. I understand my parental rights and that if I do sign this release, I voluntarily give up permanently all of my parental rights to my child. 3. I understand my right to request a rehearing or to appeal within 21 days after an order is entered terminating my parental rights. 4. I have not received or been promised any money or anything of value for the release of my child except for charges and fees approved by the court. 5. Of my own free will, I give up completely and permanently my parental rights to my child, and I release my child to for the purpose of adoption.
Child placing agency or Michigan Department of Human Services

6. 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 my child.
Date Address Parent signature City State Zip

The parent signing this release is an unemancipated minor. I am the of the minor parent, and I join with the minor parent in signing this release.
Date Address Parent signature City

parent guardian (copy of letters of authority attached) guardian ad litem (copy of order attached)

State

Zip

See reverse side for certification by judge/referee and special acknowledgment for releases by those in the armed services or in prison

Do not write below this line - For court use only

PCA 305 (11/05)

RELEASE OF CHILD BY PARENT

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 the parent her/his legal rights and that by signing this release, s/he was voluntarily giving up permanently her/his parental rights to the child. The parent then voluntarily signed this release before me. The parent, guardian, or guardian ad litem of the unemancipated minor parent was present during this hearing and voluntarily signed this release before me. The child named above is over 5 years of age, and the court finds that the child is best served by this release.

Date

Judge/Referee

Bar no.

In addition to completing the other side of this release, if the parent signing this release is in the armed services or is in prison, the following special acknowledgment must be completed by a person authorized by law to administer oaths. SPECIAL ACKNOWLEDGMENT I certify and acknowledge that
Name of parent

is personally known to me, stationed at
Name of place City State Zip

is presently
Address

confined

located at and stated

that s/he is the

mother

father

of the child. I fully explained her/his legal rights as a parent, that s/he did not

have to sign this release of her/his parental rights, and that if s/he did sign this release, s/he would be voluntarily giving up permanently her/his parental rights to the child for purposes of adoption. I also explained her/his right to a rehearing or to appeal within 21 days after an order is entered terminating her/his parental rights. The parent then voluntarily signed this release.

Subscribed and sworn to before me on
Date

,
County and state

.

My commission expires:
Date

Signature:

Notary public, State of Michigan, County of Notary Public:
Name (type or print) Address City, state, zip