Free jc50.p65 - Michigan

Approved, SCAO

JIS CODE: RQC

STATE OF MICHIGAN
JUDICIAL CIRCUIT - FAMILY DIVISION

COUNTY
Court address

REQUEST FOR CONFIDENTIALITY

CASE NO. PETITION NO.

Court telephone no.

1. In the matter of
name(s), alias(es), DOB

2. The minor is an American Indian child and either is eligible to be placed for adoption or presently is in an adoptive placement. 3. I,
Name

, am the child's natural father and ask that my identity be kept

confidential. 4. I,
Name

, am the child's natural mother and ask that my identity be kept

confidential.
Signature

Subscribed and sworn to before me on My commission expires:
Date

Date

, Signature:
Deputy clerk/Notary public

County, Michigan.

Notary public, State of Michigan, County of

Use note to court: This Request must be sent to the Secretary of the Interior with the final order of adoption if the minor is adopted.

Do not write below this line - For court use only

JC 50 (11/05)

REQUEST FOR CONFIDENTIALITY

25 USC 1951(c)