Approved, SCAO

STATE OF MICHIGAN

JUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY

PETITION FOR PLACEMENT ORDER
OF SURRENDERED NEWBORN CHILD

temporary protective custody of the newborn child named above.  The child was surrendered on

    .

2. The newborn child is believed to have been born on

Date of birth

.

JIS CODE: PCS, TCS,
and MiCOURT - PSN

CASE NO.

,  a surrendered newborn child

, a child-placing agency that assumed

Date

at

Location of birth

Date of birth:

Date of birth:

In the matter of

Full name of child

1. I am an employee of

Name of agency

3. Mother of newborn is:

Street address, city, state, zip and county

Father of newborn is:

Name

Name

Street address, city, state, zip and county

4. On

Date

Name(s)

petitioner temporarily placed the newborn with prospective adoptive parent(s),

within this county.  Their preplacement assessment has been approved by the agency.

residing at

Address

5.

a. The emergency service provider gave  information (as required by MCL 712.3) to the parent surrendering the newborn.

The information was

written (attached).

verbal and is as follows:

b. The parent surrendering the newborn gave the emergency service provider information.  The information was

written (attached).

verbal and is as follows:

c. Neither the emergency service provider or the parent surrendering the newborn exchanged written or verbal information

because:

(SEE SECOND PAGE)

Do not write below this line - For court use only

CCFD 01   (2/15)   PETITION FOR PLACEMENT ORDER OF SURRENDERED NEWBORN CHILD

MCL 712.7

I REQUEST that the court authorize the:

6. Placement of the child with the prospective adoptive parent(s).

7. Child-placing agency and prospective adoptive parent(s) to provide care for the newborn.

8. Prospective adoptive parent(s) to consent to all medical, surgical, dental, optical, psychological, educational, and related

services while having custody of the newborn.

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)

/s/
Attorney signature

Address

City, state, zip

Agency Contact Information:

Name  of  agency  representative  (type  or  print)

Agency  name

Telephone no.

E-mail

Date
/s/
Signature of petitioner

Address

Address

City, state, zip

Telephone no.

City, state, zip

Telephone no.