Approved, SCAO

STATE OF MICHIGAN

JUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY

In the matter of

Full name of child

1. I,

*Name

CONSENT TO ADOPTION BY
AGENCY/COURT

JIS CODE:  CAD

FILE NO.

DOB:

   , adoptee

, on behalf of

*Name of agency or court

as requested in a petition on file or to be filed in court.

voluntarily consent to the adoption of the child named above by

2. I am a representative authorized to execute this consent.

Date

Signature

Title

Subscribed and sworn to before me on

Date

, in

  County, Michigan.

My commission expires:

Date

Signature:

Notary public

*The consenting party in item 1 must be one of the following:

1. A representative authorized to consent on behalf of the Michigan Department of Health and Human Services or of a child-placing

agency to whom the child has been permanently committed by an order of the family division of the circuit court.

2. The family division of the circuit court having permanent custody of the child.  (Notarization not required.)

3. A representative authorized to consent on behalf of the Michigan Department of Health and Human Services or of a child-placing

agency to whom the child has been released.

4. A representative authorized to consent on behalf of a child-placing agency of another state or country, which has authority to

consent to the adoption.

5. An individual or official authorized by tribal law or order of the tribal court to give consent.

Do not write below this line - For court use only

PCA 309   (2/15)   CONSENT TO ADOPTION BY AGENCY/COURT

MCL 710.43, MCL 710.44, MCR 3.801