Approved, SCAO

STATE OF MICHIGAN

JUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY

In the matter of

Full name of child

PETITION BY PARENT/GUARDIAN FOR
RETURN OF CHILD AND
EX PARTE ORDER

JIS CODE:  PRC

FILE NO.

DOB:

 1.I am the

parent

legal guardian

with the right to legal and physical custody of the child.

2. I was assisted by

an adoption attorney

a child-placing agency

in temporarily placing the child in the home of

prospective adoptive parents.

3. The persons interested in this proceeding are:

  NAME

RELATIONSHIP

     ADDRESS

Father of Child

Mother of Child
Guardian
  of Child
Prospective
  Parent(s)
Adoption
  Attorney
Child-Placing
  Agency

4. I REQUEST that the temporary placement be revoked and that the court issue an ex parte order directing the prospective

adoptive parents to immediately return the child to me.

Signature of parent

Name (type or print)

CONSENT TO RETURN OF CHILD

I am a prospective adoptive parent and I presently have physical custody of the child.  The parent or guardian of the child has
requested that physical custody of the child be returned to him/her and that the temporary placement of the child with me be revoked.
I consent to the return of the child to the parent or guardian.

Date

Signature of parent

Name (type or print)

Date

Signature of prospective adoptive parent

Signature of prospective adoptive parent

Name (type or print)

Name (type or print)

(SEE SECOND PAGE)

Do not write below this line - For court use only

PCA 337   (2/15)   PETITION BY PARENT/GUARDIAN FOR RETURN OF CHILD AND EX PARTE ORDER

MCL 710.23d, MCL 710.23e

Date of Entry:

Judge:

IT IS ORDERED that the prospective adoptive parent(s),

shall return the child within 24 hours of receipt of this order to

the parent/guardian with authority for legal and physical custody of the child.

EX PARTE ORDER

Name(s)

Name

Judge

Bar no.

    ,