Free pca346.pmd - Michigan

Approved, SCAO

JIS CODE: VSL

STATE OF MICHIGAN
JUDICIAL CIRCUIT - FAMILY DIVISION

COUNTY

STATEMENT OF SERVICES PERFORMED BY ATTORNEY 7-DAY 21-DAY

FILE NO.

In the matter of adoptee

Full name of child

DOB: petitioner father. mother of adoptee. father of adoptee.

I am an attorney representing the

petitioner mother.

I state that the following list itemizes the services performed and any fees, compensation, or other thing of value received by or agreed to be paid to me for, or incidental to, the adoption of the child. Date Service Performed Fee, Compensation, or Other Value

SUBTOTAL from 7-Day Statement of Services Performed by Attorney
$0.00 TOTAL I represent a party in this direct placement adoption. I have not requested or received any compensation for the activities described in MCL 710.54(2).

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 Name (print or type)

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

Address City, state, zip Telephone no.

Do not write below this line - For court use only

PCA 346 (9/07)

STATEMENT OF SERVICES PERFORMED BY ATTORNEY

MCL 710.54(7)