PETITION TO ACCEPT RELEASE AND
TERMINATE RIGHTS TO
 SURRENDERED NEWBORN CHILD

Approved, SCAO

STATE OF MICHIGAN

JUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY

In the matter of

Full name of child

1. I am an employee of

Name of agency

2. The surrendering parent,

Name

Evidence demonstrating this release is attached.

3.

a. The nonsurrendering parent,

Name

JIS CODE:  ART

CASE NO.

  , a surrendered newborn child

, a child-placing agency that assumed

, has knowingly released the newborn.

, has been identified and located

temporary protective custody of the surrendered newborn child on

.

Date

and provided with notice of the surrender of the newborn as follows:  (Specify the address or location of the nonsurrendering parent
and show proof of the notice provided.)

b. The nonsurrendering parent has not been identified or located.  The following efforts were made to identify, locate, and

provide notice to the nonsurrendering parent of the surrender of the newborn:  (Specify the efforts made.)

4. 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.

5. I REQUEST the court to accept the release of the surrendering parent and to enter an order terminating the rights of the

surrendering parent.

nonsurrendering parent.

I declare that this petition has been examined by me and that its contents are true to the best of my information, knowledge, and
belief.

Attorney name (type or print)

Bar no.

Name (type or print)

Date

Signature of petitioner

Address

Attorney signature

Address

City, state, zip

Telephone no.

City, state, zip

Telephone no.

Do not write below this line - For court use only

CCFD 07   (9/07)   PETITION TO ACCEPT RELEASE AND TERMINATE RIGHTS TO SURRENDERED NEWBORN CHILD

MCL 712.17