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JIS CODE: TSN

STATE OF MICHIGAN

JUDICIAL CIRCUIT - FAMILY DIVISION

ORDER AFTER HEARING ON PETITION TO ACCEPT RELEASE AND TERMINATE RIGHTS COUNTY TO SURRENDERED NEWBORN CHILD

CASE NO.

In the matter of

Full name of child

, a surrendered newborn child Judge:
Bar no.

1. Date of hearing:

2. A petition requesting an order to accept the release of the surrendering parent and terminating the parental rights of both the surrendering and nonsurrendering parents has been filed by Name of agency a child-placing agency. THE COURT FINDS by a preponderance of the evidence that: 3. The surrendering parent, Name the newborn. 4. a. The nonsurrendering parent,
Name

,

,

has

has not

knowingly released

, has been identified and located and provided

with notice of the surrender of the newborn. b. The nonsurrendering parent has not been identified or located, and the child-placing agency has made reasonable efforts to provide notice of the surrender of the newborn. 5. The surrendering parent nonsurrendering parent has not filed a petition for custody of the newborn within the required 28 days following notice of the surrender of the newborn. IT IS ORDERED: 6. The release of the surrendering parent 7. The parental rights of the is is not accepted. nonsurrendering parent are terminated. Custody and ,a that authorizes placement of

surrendering parent

care of the surrendered newborn child is granted to child-placing agency. The prior court order dated the surrendered newborn child with the prospective adoptive parent(s) is continued. 8. The petition is denied. 9. Other:

Date

Judge

Do not write below this line - For court use only

CCFD 08 (9/07)

ORDER AFTER HEARING ON PETITION TO ACCEPT RELEASE AND TERMINATE RIGHTS TO SURRENDERED NEWBORN CHILD MCL 712.17