Free pca330.p65 - Michigan

Approved, SCAO

JIS CODE: TCA

STATE OF MICHIGAN
JUDICIAL CIRCUIT - FAMILY DIVISION

COUNTY

STATEMENT OF PARENT/GUARDIAN TRANSFERRING PHYSICAL CUSTODY OF CHILD FOR ADOPTION

FILE NO.

In the matter of the child 1. I am a parent

Full name of child

DOB:

guardian

with legal and physical custody of the child and am being assisted in the temporary . (attach copy of current letters of authority)

placement of the child by 2. On
Date

Name of adoption attorney or agency

, for the purpose of adoption, physical custody of the child was transferred to:
Name(s) of parent(s) City

a. prospective adoptive parent(s) County at

who reside(s) in .

Street address

Zip

b. Unknown to me because identifying information is not being exchanged. 3. I understand that I retain full parental rights to my child. I agree that the prospective adoptive parent may consent to all medical, surgical, psychological, educational, and related services for my child during the temporary placement. 4. I understand that this temporary placement may be revoked by me by filing a petition in this court requesting that my child be returned to me. 5. 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 parents of an adoptee. 6. The names and addresses of the mother and father are: Mother:
Name Street address City State Zip

She is a minor. The name and address of the parent or guardian who agreed with the placement are
Name(s) Street address City Street address State City Zip State Zip

.

Father:

Name

He is a minor. The name and address of the parent or guardian who agreed with the placement are
Name(s)

.
Street address City State Zip

(PLEASE SEE OTHER SIDE)
Do not write below this line - For court use only

MCL 710.23d PCA 330 (9/06)

STATEMENT OF PARENT/GUARDIAN TRANSFERRING PHYSICAL CUSTODY OF CHILD FOR ADOPTION

6. continued. The name and address of each other possible putative father are: . 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/agency official Name of parent/guardian/agency official (print) Signature of parent/guardian/agency Name of parent/guardian/agency official (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
Name of parent of child

who is an unemancipated minor parent of the child. I have reviewed this statement and agree with the temporary placement.
Date Signature of parent/guardian Name of parent/guardian (print) Address City, state, and zip Signature of witness Name of witness (print)

REPORT TO COURT FOLLOWING TEMPORARY PLACEMENT I report that I am assisting in the temporary placement of child who was placed for purposes of adoption in the home of adoptive parents as set forth in this statement. The statement of the prospective adoptive parents evidencing transfer of physical custody of the child to them is attached. The parent(s) and prospective adoptive parent(s) have elected not to exchange identifying information. The name(s) and address of the prospective adoptive parent(s) are:
Name(s) Street address City State Zip

I declare that the statement in this report has been examined by me and that its contents are true to the best of my information, knowledge, and belief.
Date Name of attorney or agency representative (print) Name of firm or agency Signature of attorney or agency representative Address City, state, and zip