Approved, SCAO

STATE OF MICHIGAN

JUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY

In the matter of

Full name of child

 1.On

Date

PETITION TO
DETERMINE CUSTODY OF CHILD
TEMPORARILY PLACED FOR ADOPTION

FILE NO.

DOB:

JIS CODE:  PDC

 the child was temporarily placed in the home of the prospective adoptive parent(s).

2. Physical custody of the child was transferred to the prospective adoptive parents by

a. the parent/guardian with legal and physical custody of the child with the assistance of

an adoption attorney.

a child-placing agency.

b. the child-placing agency having written authorization from the parent or guardian to make the temporary placement.

3. The persons interested in this proceeding are:  (Include father and mother if their parental rights have not been terminated.)

  NAME

RELATIONSHIP

     ADDRESS

Father of Child

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

4.

The mother of the child is a minor.  The name and address of the minor mother's parent or guardian who agreed with the
placement are

The father of the child is a minor.  The name and address of the minor father's parent or guardian who agreed with the
placement are

City

State

Zip

.

.

Name

Address

Name

Address

City

State

Zip

(SEE SECOND PAGE)

Do not write below this line - For court use only

PCA 335   (2/15)   PETITION TO DETERMINE CUSTODY OF CHILD TEMPORARILY PLACED FOR ADOPTION

MCL 710.23d

5. An action within the jurisdiction of the family division of circuit court involving the family or family members of the minor has

been previously filed in

assigned to Judge

Court, Case Number

 , was

, and

remains

is no longer

pending.

6.

a. I am the prosecuting attorney for this county.  I have been notified that an adoption petition has not been filed and the

child has not been returned to the parent or person having the right to legal custody.

b. I am the prospective adoptive parent.  I am unwilling or unable to proceed with the adoption.  Physical custody of the

should not be returned to the

parent

legal guardian

agency

child
for the following reasons:

should

c. I am the representative of the child-placing agency that temporarily placed the child.  I state that

the agency is unable to proceed with adoption because of the unavailability of a parent or guardian to execute a release.

the agency has legal rights to custody of the child and chooses not to proceed further with the adoption of the child
by the prospective adoptive parents.

the parent or guardian who authorized temporary placement desires to regain custody of the child.

7. I REQUEST that the court determine the custody of the child.

Date

Signature of petitioner

Name of petitioner (type or print)

Agency name

Address

City, state, and zip

Telephone no.