Free pc650.p65 - Michigan

Approved, SCAO

JIS CODE: LGM

STATE OF MICHIGAN PROBATE COURT COUNTY
CIRCUIT COURT - FAMILY DIVISION

FILE NO. PETITION FOR APPOINTMENT OF LIMITED GUARDIAN OF MINOR XXX-XXLast four digits of SSN.

In the matter of 1. I am interested in this matter and make this petition as custodial parent of the minor.

, a minor

2. An action within the jurisdiction of the family division of circuit court involving the family or family members of the minor has been previously filed in assigned to Judge 3. The minor was born
Date

Court, Case Number , and , is female, remains is no longer

, was pending.

male, is unmarried, resides in
County City/Township

at

Address Zip

State

, and is presently located in

County City/Township

at
Address (only if different than above) State Zip

.

The minor is a citizen of the following foreign country: The minor is a biological child of a member of
Name of tribe/band

an American Indian tribe/band and is

a member of or is eligible to be a member of that tribe/band. 4. The persons interested in this proceeding are:
NAME RELATIONSHIP ADDRESS

Father/Age Mother/Age Conservator Guardian Person with care/ custody of minor*
* also list persons who had principal care and custody of minor during the 63 days preceding filing of petition

5. The welfare of the minor will be served by the appointment. 6. A proposed limited guardianship placement plan is attached.

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

PC 650 (9/06)

PETITION FOR APPOINTMENT OF LIMITED GUARDIAN OF MINOR

MCL 700.5205, MCR 5.125(C)(19), MCR 5.404

I REQUEST: 7.
Name City/Township State Zip

whose address is
Address

be appointed limited guardian of the minor.
Telephone no.

8. Other:

9. I CONSENT TO THE SUSPENSION OF MY PARENTAL RIGHTS. I declare under the penalties of perjury that this petition has been examined by me and that its contents are true to the best of my information, knowledge, and belief.
Date Signature of custodial father Address City, state, zip Telephone no. Date Signature of custodial mother Address City, state, zip Telephone no.

NOTE: If both parents have custody, each must sign. 10. I am 14 years of age or older. I nominate
Name

as my guardian

who lives at
Address City State Zip

Date

Signature of minor

Attorney signature Attorney name (type or print) Address City, state, zip Telephone no. Bar no.