Consent to Adoption

CONSENT TO ADOPTION BY PARENT

In the matter of

NOTE: If the child is an Indian child, use form PCA 308-1.

1. I, am the mother (Date of birth ) father (Date of birth )

of the child named above, who was born at , adoptee

2. A judge or referee of the court, or other authorized person, has fully explained to me my legal rights as a parent and that I do not have to sign this consent to adoption. I understand my parental rights and that if I do sign this consent, I voluntarily and permanently give up all my parental rights to my child for adoptive placement with

a. the petitioner(s), who filed a petition for the adoption of the adoptee and whose name(s) is/are unknown because identifying information is not being exchanged.

b. , who filed a petition for adoption of my child.

3. I understand my right to request a rehearing or to appeal within 21 days after an order is entered terminating my parental rights.

4. I have not received or been promised any money or anything of value for the consent to adopt my child except for charges and fees approved by the court.

5. Of my own free will, I give up completely and permanently my parental rights to my child, and I consent to the adoption of my child by the petitioner(s).

6. I understand that my parental rights may be reinstated without further hearing if the adoption of the child named above is not confirmed.

Parent name (type or print)

The parent signing this consent is an unemancipated minor. I am the parent

guardian (Copy of letters of authority attached.)

guardian ad litem (Copy of order attached.)

of the minor parent, and I join with the minor parent in signing this consent.

See second page for certification by judge/referee
and special acknowledgment for consents by those in the armed services or in prison.

Do not write below this line - For court use only

CERTIFICATION BY JUDGE/REFEREE

NOTE: Before taking the consent, the court shall obtain from the parent(s) all the nonidentifying information required by MCL 710.27.

An investigation of this consent has been made. At a hearing where a verbatim record of testimony was made, I explained to the parent her/his legal rights and that by signing this consent, s/he was voluntarily and permanently giving up her/his parental rights to the child for adoption by the petitioner(s). The parent then voluntarily signed this consent before me.

The parent, guardian, or guardian ad litem of the unemancipated minor parent was present during this hearing and voluntarily signed this consent before me.

NOTE: The following direction is necessary only if the consent is signed before another judge of the family division of the circuit court in Michigan (MCL 710.44[1]). In other cases, see MCL 710.44(2),(4).

I direct that the consent of be signed before the judge of

or his/her designated referee.

In addition to completing the other side of this consent, if the parent signing this consent is in the armed services or is in prison, the following special acknowledgment must be completed by a person authorized by law to administer oaths.

SPECIAL ACKNOWLEDGMENT

I certify and acknowledge that is personally known to me,

is presently confined stationed at located at

and stated that s/he is the mother father of the child. I fully explained her/his legal rights as a parent, that s/he did not have to sign this consent to adoption, and that if s/he did sign this consent, s/he would be voluntarily and permanently giving up her/ his parental rights to the child for purposes of adoption. I also explained her/his right to a rehearing or to appeal within 21 days after an order is entered terminating her/his parental rights. The parent then voluntarily signed this consent.

Subscribed and sworn to before me on

My commission expires: Signature:

Notary public, State of Michigan, County of

Notary Public:

Name (type or print)

Address

City, state, zip