Fill and Sign the Nal School Safety Center Ncjrs Form

In the matter of, a surrendered newborn child 1. I am the mother father of the above named newborn child born on at . 2. The newborn was surrendered to , an emergency services provider located at . The surrender was made by the mother father on , less than 28 days from filing this petition. 3. The newborn is located in County, Michigan. I do not know where the child is presently located. 4. Mother of newborn: Date of birth: Father of newborn: Date of birth: 5. I wish to revoke surrender of my child and release of parental rights, if any. I REQUEST: 6. That I be given custody of the child and that blood or tissue typing be ordered upon filing of this petition. 7. Other: I declare that this petition has been examined by me and that its contents are true to the best of my information, knowledge, a nd belief. Approved, SCAO CASE NO. STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION COUNTY CCFD 03 (1/01) PETITION OF PARENT FOR CUSTODY OF SURRENDERED NEWBORN CHILD PETITION OF PARENT FOR CUSTODY OF SURRENDERED NEWBORN CHILD MCL 712.10 Full name of childDate of birth Location of birth Name of emergency services provider (indicate if unknown) Street address, city, and county of emergency services provider Do not write below this line - For court use only Signature of petitioner Name (type or print) Address City, state, zip Telephone no.Bar no. Date Telephone no. City, state, zip Address Name (type or print) Street address, city, state, zip and county Street address, city, state, zip and county Signature of petitioner Name Name Date