Fill and Sign the To Adoptee Form

Approved, SCAO In the matter of Full name of child , adoptee JIS CODE: DPA Do not write below this line - For court use only (See additional pages) STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION COUNTY PETITION FOR DIRECT PLACEMENT ADOPTION FILE NO. PCA 301a (6/17) PETITION FOR DIRECT PLACEMENT ADOPTION MCL 710.24, MCL 710.46, MCL 710.56, MCL 712B.9(1) The petitioners are: Name Relationship to Adoptee Address, City, State, Zip Date and Place of Birth Adopting parent Maiden: Adopting parent Maiden: Each adopting petitioner states: 1. 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 Court, Case Number , was assigned to Judge , and remains is no longer pending. 2. The adoptee was born on Birth date and time at City, county, and state of birth . parent/guardian. 3. The adoptee was temporarily placed in my home on Date by a child-placing agency. 4. The adoptee will be my heir at law. not be changed. 5. The adoptee’s name will be changed to First Middle Last . 6. The adoptee’s property is . 7. The parties have elected not to exchange identifying information. Verified statement of identifying information (form PCA 340) attached. Note: Do not complete items 8 and 9 if item 7 is checked. 8. The adoptee is Full name of child (type or print) Present residential address (if known) The adoptee’s parents are: Father’s name (type or print) Birth date Mother’s name and maiden name (type or print) Birth date Address Address City, state, zip City, state, zip 9. The adoptee’s court-appointed guardian and/or conservator is/are Name(s) and address(es) . Petition for Direct Placement Adoption (6/17) Page of File No. 10. I have received a copy of the reasonably obtainable nonidentifying information required for a placement of the child for adoption. A copy is attached. have have not 11. I have been informed of the availability of counseling services. I received counseling. 12. No preplacement assessments have been completed on us other than those attached. Preplacement assessments have been started but not completed as follows: (Attach separate sheet as needed.) 13. I am married but my spouse is not joining me in this petition because 14. The adoptee is an Indian child as defined in MCR 3.002(12). The identity of the tribe is Name of tribe, if known . The appropriate consents have been executed pursuant to MCL 712B.13 and the Michigan Adoption Code. I REQUEST: 15. Termination of all existing parental rights inconsistent with the order of adoption, entry of an order approving placement of the child with me, and entry of an order of adoption with the adoptee’s name recorded as stated in item 5. 16. The adoption be completed immediately because 17. The court to waive the required investigation because the adoptee has been placed in foster care with me for at least 12months and a foster family study was completed or updated within the last 12 months. I declare that the statements above are true to the best of my information, knowledge, and belief. Attorney signature Date Attorney name (type or print) Bar no. Signature of petitioner Address Signature of petitioner City, state, zip Telephone no. Petitioner telephone no. Agency Contact Information: Name of agency representative (type or print) Address Agency name City, state, zip Telephone no. E-mail /s/ /s/ /s/ Petition for Direct Placement Adoption (6/17) Page of File No. IT IS ORDERED: 18. The preplacement assessment filed with the petition has been reviewed by the court and a. it is a sufficient investigation of the adoptive home, and no further investigation is required. b. Court agent or employee, child-placing agency is directed to conduct an additional investigation and report its findings in writing to this court, within 3 months of this order, in accordance with the provisions of section 46 of the Michigan Adoption Code. 19. The full investigation is waived. The petitioner(s) shall file a copy of the most recent foster family study as updated and supplemented. 20. The petitioner(s) shall give notice of this petition to the persons prescribed in MCR 3.800(B) in accordance with MCR 3.802(A)(3) (use form PCA 352). Date Judge Bar no.