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Here is the text we could read:

Name

Address, City, State, Zip

Relationship
to Adoptee

Date and Place
of Birth

, adoptee

1. An action within the jurisdiction of the family division of circuit court involving the family or family members of the minor

Court, Case Number

, was

, and

remains

is no longer pending.

2. The adoptee was born on

3. The adoptee was temporarily placed in my home on

Birth date and time

at
City, county, and state of birth

by a

parent/guardian.
child-placing agency.

Date

First Middle Last

7. The parties have elected not to exchange identifying information. Verified statement of identifying information (form PCA 340) attached.

4. The adoptee will be my heir at law.

5. The adoptee’s name will

not be changed.
be changed to

6. The adoptee’s property is

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

City, state, zip

Address

City, state, zip

9. The adoptee’s court-appointed guardian and/or conservator is/are

Name(s) and address(es)

In the matter of

Full name of child

The petitioners are:

Adopting parent

Maiden:

Adopting parent

Maiden:
Each adopting petitioner states:

has been previously filed in

assigned to Judge

Approved, SCAOJIS CODE: DPADo not write below this line - For court use only(See additional pages)STATE OF MICHIGANJUDICIAL CIRCUIT - FAMILY DIVISIONCOUNTY PETITION FOR DIRECT PLACEMENT ADOPTION FILE NO.PCA 301a (6/17) PETITION FOR DIRECT PLACEMENT ADOPTIONMCL 710.24, MCL 710.46, MCL 710.56, MCL 712B.9(1)Petition for Direct Placement Adoption

(6/17) Page

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.

11. I have been informed of the availability of counseling services. I

have

have not

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:

13. I am married but my spouse is not joining me in this petition because

(Attach separate sheet as needed.)

14. The adoptee is an Indian child as defined in MCR 3.002(12). The identity of the tribe is

The appropriate consents have been executed pursuant to MCL 712B.13 and the Michigan Adoption Code.

Name of tribe, if known

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 12

months 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.

/s/
Attorney signature

Address

City, state, zip

Attorney name (type or print) Bar no.

Date
/s/
Signature of petitioner
/s/
Signature of petitioner

Telephone no.

Petitioner telephone no.

Agency Contact Information:

Name of agency representative (type or print)

Agency name

Telephone no.

E-mail

Address

City, state, zip

Petition for Direct Placement Adoption

(6/17) Page

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.

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.

PCA 301a, Petition for Direct Placement Adoption

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the Michigan state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from www.courts.michigan.gov/adoptions-court-forms (2023-03)
Page(s): 3
Fields(s): 87
Average fields per page: 29
Reading Level: Grade 8
LIST Grouping(s): FA-00-00-00-00.

Use our Rate My PDF tool to learn more. Go beyond the above insights and learn more about this or any pdf form at RateMyPDF.com, includes: counts of difficult words used, passive voice decetion, and suggestions for how to make the form more usable.

Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

Here are the fields we could identify.

stat_e_n_l_county was STATE OF MICHIGAN JUDICIAL CIRCUIT FAMILY DIVISION COUNTY (0.64 conf)
full_name_child was Full name of child (0.35 conf)
adopting_parent__1 was Adopting parent (0.49 conf)
relationship_adopting_parent__1 was Relationship to AdopteeAdopting parent Maiden (0.42 conf)
address_city_state_adopting__1 was Address City State ZipAdopting parent Maiden (0.44 conf)
date_place_adopting_parent__1 was Date and Place of BirthAdopting parent Maiden (0.33 conf)
adopting_parent__2 was Adopting parent_2 (0.40 conf)
relationship_adopting_parent__2 was Relationship to AdopteeAdopting parent Maiden_2 (0.42 conf)
address_city_state_adopting__2 was Address City State ZipAdopting parent Maiden_2 (0.38 conf)
date_place_adopting_parent__2 was Date and Place of BirthAdopting parent Maiden_2 (0.38 conf)
action_division_involving was 1 An action within the jurisdiction of the family division of circuit court involving the family or family members of the minor (0.37 conf)
court_case_number was Court Case Number (0.46 conf)
was was was (0.41 conf)
and was and (0.41 conf)
remains was remains (0.32 conf)
longer was is no longer (0.37 conf)
birth_date_time was Birth date and time (0.43 conf)
city_county_state_birth was City county and state of birth (0.47 conf)
temporarily_placed_home was 3 The adoptee was temporarily placed in my home on (0.34 conf)
signature_date__1 was Date (1.00 conf)
parentguardian was parentguardian (0.35 conf)
childplacing_agency was childplacing agency (0.54 conf)
changed__1 was not be changed (0.41 conf)
changed__2 was be changed to (0.44 conf)
first was First (0.34 conf)
middle was Middle (0.31 conf)
last was Last (0.34 conf)
undefined__1 was undefined (0.38 conf)
information_verified_statement was 7 The parties have elected not to exchange identifying information Verified statement of identifying information form PCA 340 attached (0.37 conf)
full_name_child_type_print was Full name of child type or print (0.44 conf)
present_address_known was Present residential address if known (0.45 conf)
fathers_name_type_print was Fathers name type or print (0.49 conf)
birth_date__1 was Birth date (0.43 conf)
mothers_name_maiden_type_print was Mothers name and maiden name type or print (0.41 conf)
birth_date__2 was Birth date_2 (0.44 conf)
users1_address_line_one was Address (1.00 conf)
address__1 was Address_2 (0.35 conf)
users1_address_line_two was City state zip (1.00 conf)
city_state_zip__1 was City state zip_2 (0.35 conf)
adoptees_andor_conservator was 9 The adoptees courtappointed guardian andor conservator isare (0.45 conf)
names_addresses was Names and addresses (0.47 conf)
undefined__2 was undefined_2 (0.39 conf)
text__1 was Text1 (0.35 conf)
text__2 was Text2 (0.35 conf)
text__3 was Text3 (0.35 conf)
text__4 was Text4 (0.35 conf)
text__5 was Text5 (0.35 conf)
information_required_placement was 10 I have received a copy of the reasonably obtainable nonidentifying information required for a placement of the child (0.39 conf)
availability_services was 11 I have been informed of the availability of counseling services I (0.34 conf)
assessments_completed_us was 12 No preplacement assessments have been completed on us other than those attached (0.35 conf)
spouse_joining_needed was 13 I am married but my spouse is not joining me in this petition because Attach separate sheet as needed (0.43 conf)
adoptee_indian_child_defined_mc_r_identity_tribe was 14 The adoptee is an Indian child as defined in MCR 300212 The identity of the tribe is (0.36 conf)
of was of (0.38 conf)
have was have (0.45 conf)
have_not was have not (0.45 conf)
assessments_completed_follows was Preplacement assessments have been started but not completed as follows (0.48 conf)
name_tribe_known was Name of tribe if known (0.35 conf)
appropriate_pursuant_mc_michigan was The appropriate consents have been executed pursuant to MCL 712B13 and the Michigan Adoption Code (0.42 conf)
adoption_completed_immediately was 16 The adoption be completed immediately because (0.41 conf)
waive_required_least was 17 The court to waive the required investigation because the adoptee has been placed in foster care with me for at least 12 (0.38 conf)
signature_date__2 was Date_2 (1.00 conf)
attorney_name_type_print was Attorney name type or print (0.50 conf)
bar__1 was Bar no (0.41 conf)
address__2 was Address_3 (0.35 conf)
city_state_zip__2 was City state zip_3 (0.35 conf)
telephone__1 was Telephone no (0.44 conf)
petitioner_telephone was Petitioner telephone no (0.45 conf)
agency_representative_type was Name of agency representative type or print (0.46 conf)
address__3 was Address_4 (0.35 conf)
agency_name was Agency name (0.47 conf)
city_state_zip__3 was City state zip_4 (0.35 conf)
telephone__2 was Telephone no_2 (0.45 conf)
email was Email (0.38 conf)
text__6 was Text6 (0.35 conf)
text__7 was Text7 (0.35 conf)
text__8 was Text8 (0.35 conf)
text__9 was Text9 (0.35 conf)
text__10 was Text10 (0.35 conf)
text__11 was Text11 (0.35 conf)
page was Page (0.27 conf)
filed_petition_court was 18 The preplacement assessment filed with the petition has been reviewed by the court and (0.41 conf)
investigation_petitioners_recent_updated was 19 The full investigation is waived The petitioners shall file a copy of the most recent foster family study as updated and (0.36 conf)
shall_give_notice_accordance was 20 The petitioners shall give notice of this petition to the persons prescribed in MCR 3800B in accordance with MCR (0.42 conf)
sufficient_home_required was a it is a sufficient investigation of the adoptive home and no further investigation is required (0.44 conf)
b was b (0.34 conf)
court_employee_agency was Court agent or employee childplacing agency (0.46 conf)
signature_date__3 was Date_3 (1.00 conf)
bar__2 was Bar no_2 (0.37 conf)

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The Legal Innovation & Technology Lab's Form Explorer Beta @ Suffolk Law School Last updated 2023-04-02

PCA 301a, Petition for Direct Placement Adoption

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Identified Data Fields:

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The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02