Approved, SCAO

STATE OF MICHIGAN

JUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY

In the matter of

Full name of child

ORDER PLACING
SURRENDERED NEWBORN WITH
PROSPECTIVE ADOPTIVE PARENTS

FILE NO.

JIS CODE:  ONA

          , a surrendered newborn child

Bar no.

1. Date of hearing:

Judge:

2. A petition requesting an order for authority to place the child with prospective adoptive parent(s) has been filed by

, a child-placing agency.

and was surrendered to an emergency service provider on

Name of agency

3. The child was born on

Date

Date

.

IT IS ORDERED:

City, state, zip

4. THE COURT FINDS that an order to place the child and to provide care for the child is necessary.

5. The child-placing agency is authorized to place the child with the prospective adoptive parents,

Name(s)

, residing at

Address

.

6. The child-placing agency and the prospective adoptive parent(s) shall provide care for the child and each is authorized to consent

to all medical, surgical, dental, optical, psychological, educational, and related services.

7. The child-placing agency shall supervise the child in the home of the prospective adoptive parent(s) and shall report to the court
as directed.  The child shall not be removed from the home without court order and shall not be removed from the State of
Michigan.

Date

Judge

Do not write below this line - For court use only

CCFD  02   (9/07)   ORDER PLACING SURRENDERED NEWBORN WITH PROSPECTIVE ADOPTIVE PARENTS

MCL 712.7



Order Placing Surrendered Newborn with Prospective Adoptive Parents

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About This Form:

• Sourced from www.courts.michigan.gov/safe-delivery-newborn (2023-03)
• Page(s): 1
• Fields(s): 15
• Average fields per page: 15
• Reading Level: Grade 8
• LIST Grouping(s): FA-14-00-00-00, FA-00-00-00-00.

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