Free pca340.pmd - Michigan

Approved, SCAO

JIS CODE: SII

STATE OF MICHIGAN
JUDICIAL CIRCUIT - FAMILY DIVISION

FILE NO. STATEMENT OF IDENTIFYING INFORMATION

COUNTY

In the matter of adoptee

Full name of child

DOB:

1. I am assisting the

parent

guardian

in this adoption.

2. The parties have elected not to exchange identifying information. 3. The surname and current place of residence of the adoptee are
Address Name

.

4. The name and address of each parent are:
Name and address of mother Name and address of father

5. The name and address of the court-appointed guardian of the adoptee are
Name Address

.

I declare that this statement has been examined by me and that its contents are true to the best of my information, knowledge, and belief.
Date Signature of attorney or agency representative Name of attorney or agency representative (print) Name of firm or child-placing agency Address City, state, zip Telephone no. Bar no.

Do not write below this line - For court use only

PCA 340 (9/07)

STATEMENT OF IDENTIFYING INFORMATION

MCL 710.24(5)