STATE OF MICHIGAN

PROBATE COURT
COUNTY

CONSENT BY 
PARENT/INDIAN CUSTODIAN
TO GUARDIANSHIP OF INDIAN CHILD

CASE NO. and JUDGE

Court address              

 

 

 

Court telephone no.

 

 

 .

 .

2. A judge has fully explained to me my legal rights as a parent/Indian custodian and that I do not have to sign this voluntary 
  consent to a petition for guardianship. The explanation given to me was in a language understood by me or interpreted 
 
  voluntarily  suspend all of my parental rights to the child for placement with a guardian.

into my own language if I do not speak English. I understand my parental rights and that if I do sign this consent, I 

3. This consent is not given before or within 10 days after the birth of the child.

4. I understand that I may withdraw my consent at any time by sending written notice to the court substantially in compliance
  with a form approved by the State Court Administrative Office and that, upon receipt of that notice, the court will 
 

immediately enter an ex parte order terminating the guardianship and returning the child to me.

5. Of my own free will, I consent to the guardianship of the child by the petitioner(s). The name and address of the person 

First, middle, and last name of child

Name of tribe and identification no. (if one)

 , 

of the child named above, who was born  

Put DOB in Ref. No. 
row 10 on MC 97a
Date

 at 

Place

 , am the 

 parent (Age 
 Indian custodian 

 

 ) 

 

 

 

In the matter of 

1. I, 
 

Name

                     

   

  with whom my child will be placed is 

Name and address of proposed guardian

Date
 
 

 

Parent/Indian custodian signature

Address                                                                                                                   City                                                          State                             Zip

1. Notice of this proceeding was given as required by MCR 5.109(1).

CERTIFICATION BY JUDGE

2. At a hearing where a verbatim record of testimony was made, I explained to the parent/Indian custodian her/his legal 
rights under MCL 712B.13 and that, by signing this consent, s/he was voluntarily suspending her/his parental rights to 
 
 
the Indian  child for placement with the proposed guardian. The parent/Indian custodian then voluntarily signed this 
  consent.

 

                     

Judge signature and date

Approved, SCAO
Form PC 686, Rev. 12/21
MCL 700.5204, MCL 700.5205, MCL 712B.13, MCL 712B.25(3)-(5), 
MCR 5.404(B)
Page 1 of 2

PCS Code: CGITCS Code: CGIConsent by Parent/Indian Custodian to Guardianship of Indian Child 
Page 2 of 2

(12/21) 

Case No. 
 

This proceeding was translated by me to the parent/Indian custodian in his/her spoken language 

STATEMENT OF INTERPRETER

of 

Spoken language

 

                     

Signature of interpreter

 .

 . 

Subscribed and sworn to before me on 
 
 

                     
                     

Date

My commission expires on 
 
Notary public, State of Michigan, County of 

                     

 

 

 

 

 

 

 

 

 

 

Deputy clerk/Notary public signature

Name (type or print)
 

 

 . 

 Acting in the County of 

 

 . 
 

 .

 This notarial act was performed using an electronic notarization system or a remote electronic notarization platform.

Address                                                                                                                  City                                                             State                             Zip