Free pca332a.p65 - Michigan

Approved, SCAO

JIS CODE: SNR

STATEMENT OF NONRESIDENT PROSPECTIVE FILE NO. JUDICIAL CIRCUIT - FAMILY DIVISION ADOPTIVE PARENT COUNTY TRANSFERRING PHYSICAL CUSTODY OF CHILD FOR ADOPTION STATE OF MICHIGAN In the matter of the child
Full name of child

DOB:

1. Physical custody of the child was transferred to me on 2. I am a prospective adoptive parent and a resident of

Date

. . I agree to obtain approval in

State

compliance with the Interstate Compact on Placement of Children before the child is sent, brought, or caused to be sent or brought into County, Michigan. I agree to submit to the jurisdiction of the State of Michigan.

3. The temporary placement will not become formal until both parents consent to adoption or release their parental rights and the court orders the termination of parental rights of both parents and approves the placement. 4. I understand if the court enters an order directing return of the child to the parent or guardian with legal custody, I must return physical custody of the child to the parent or guardian named in the order within 24 hours of being served with the court order.

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 prospective adoptive parent Name of prospective adoptive parent (print) Signature of prospective adoptive parent Name of prospective adoptive parent (print) Address City, state, and zip Signature of witness Name of witness (print)

Do not write below this line - For court use only

PCA 332a (9/06)

STATEMENT OF NONRESIDENT PROSPECTIVE ADOPTIVE PARENT TRANSFERRING PHYSICAL CUSTODY OF CHILD FOR ADOPTION MCL 710.23d