Free pca329.pmd - Michigan

Approved, SCAO

JIS CODE: ATA

STATE OF MICHIGAN

JUDICIAL CIRCUIT - FAMILY DIVISION

STATEMENT OF PARENT/GUARDIAN AUTHORIZING TEMPORARY PLACEMENT OF COUNTY CHILD FOR ADOPTION

FILE NO.

In the matter of the child

Full name of child

DOB: mother. father. court. (Copy of order is attached.) , a child-placing agency, to make a

1. I have legal and physical custody of the child as guardian pursuant to an order issued by the 2. I authorize

Name of court

temporary placement of the child with prospective adoptive parents in accordance with the Michigan Adoption Code, and a. I have read a preplacement assessment of the prospective adoptive parent(s) that was completed or updated less than a year ago and which states that the prospective adoptive parent(s) are suitable to be parent(s) of an adoptee. OR b. I have been informed that the child-placing agency must give me an opportunity to review the preplacement assessment of the prospective adoptive parent(s) before any temporary placement. 3. I have been informed that I retain full parental rights to the child and that the agency must file a petition on my behalf if I wish to regain custody of my child during the temporary placement in the adoptive home. 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 parent/guardian Name of parent/guardian (print) Signature of parent/guardian Name of parent/guardian (print) Signature of witness Name of witness (print) Signature of witness Name of witness (print)

CERTIFICATION BY PARENT/GUARDIAN OF UNEMANCIPATED MINOR PARENT I certify that I am the parent legal guardian of who is an unemancipated minor parent of the child. I join with the parent in authorizing the child-placing agency to make a temporary placement of the child with the prospective adoptive parents.
Date Signature of parent/guardian Name of parent/guardian (print) Address City Signature of witness Name of witness (print) State Zip

Do not write below this line - For court use only

PCA 329 (9/07)

STATEMENT OF PARENT/GUARDIAN AUTHORIZING TEMPORARY PLACEMENT OF CHILD FOR ADOPTION

MCL 710.23b, MCL 710.23d