Free pca345.pmd - Michigan

Approved, SCAO

JIS CODE: VSD

STATE OF MICHIGAN
JUDICIAL CIRCUIT - FAMILY DIVISION

COUNTY

STATEMENT OF SERVICES PERFORMED BY AGENCY/ DEPARTMENT OF HUMAN SERVICES 7-DAY 21-DAY

FILE NO.

In the matter of adoptee

Full name of child

DOB:

I state that the following list itemizes the services performed and any fee, compensation, or other thing of value received by or agreed to be paid to the child-placing agency or the Michigan Department of Human Services for, or incidental to, the adoption of the child.
(NOTE: If no fee, compensation, or other thing of value is paid or agreed to be paid, you must write "NONE" in the fee column.)

Date

Service Performed

Fee, Compensation, or Other Value

SUBTOTAL from 7-Day Statement of Services Performed by Agency

$0.00 TOTAL The child-placing agency or Michigan Department of Human Services has not requested or received any compensation for the activities described in MCL 710.54(2).
I am a representative of the child-placing agency/Michigan Department of Human Services and have authority to make this statement. 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 child-placing agency/DHS representative Name (print or type)

NOTE: Attach this statement to form PCA 347, "Petitioner's Verified Accounting"

Name of agency (print or type) Address City, state, zip Telephone no.

Do not write below this line - For court use only

MCL 710.54(7) PCA 345 (9/07)

STATEMENT OF SERVICES PERFORMED BY AGENCY/DEPARTMENT OF HUMAN SERVICES