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Here is the text we could read:

STATE OF MICHIGAN

PROBATE COURT
COUNTY

LIMITED GUARDIANSHIP
PLACEMENT PLAN

CASE NO. and JUDGE

Court address

Court telephone no.

In the matter of

First, middle, and last name of minor

Special Note in Completing Form:
Items 1 through 4 must be completed to comply with MCL 700.5205(2).
Each custodial parent who signs this plan is agreeing to all the conditions of the plan even though each item refers to a
single person. When more than one parent enters into this agreement and they differ from one another in any area of the
plan, each parent must complete their own plan on separate forms. For example:

• If they differ in their reasons for the guardianship, each parent must specify their own reasons.

This plan modifies a limited guardianship placement plan previously approved by the court.

As custodial parent, I desire to establish a limited guardianship for my child and agree to the following plan:

1. The reason I want a limited guardianship is:

To enable my child to attend school in the proposed guardian’s school district.

To provide health insurance through the proposed guardian.

I will be or am incarcerated until

I am currently without housing adequate for my child.

I am unable to care for my child because of my health.

I am unable to care for my child because of my mental instability.

I desire an alternative to action recommended by child protective services.

I have lost substantial control of my child’s behavior.

I need to improve my parenting skills.

The minor’s physical needs for food, clothing, and housing may best be met by the proposed guardian.

To comply with the requirement of the

Reserves.

Armed Forces.

Other:

Approved, SCAO
Form PC 652, Rev. 4/22
MCL 700.5205(2), MCR 5.404(A), (B)
Page 1 of 3

Approved:

FOR COURT USE ONLY

Judge signature and date

JIS Code: LGPLimited Guardianship Placement Plan
Page 2 of 3

(4/22)

Case No.

2. Visits and contact with my child will be sufficient to maintain my parent and child relationship and will be as follows:

I will visit my child on: (please mark each day you plan to visit)

___ Su

___ M

___ Tu

___ W

___ Th

___ F

___ Sa

from: (please specify the time)

.m.

I will visit my child

times each

week.

month.

Visits will occur at

my residence.

the proposed guardian’s residence.

Telephone contact will take place

daily.

weekly.

monthly.

Letters will be sent

daily.

weekly.

monthly.

I will attend my child’s school conference provided I receive timely notice of the conference.

I will attend counseling with my child.

I will participate in and arrange positive outings with my child

daily.

weekly.

monthly.

I will provide transportation for my child for

I will attend all doctor/dental appointments for my child (excluding emergencies).

Transportation to and from visits with my child will be the responsibility of

Collect telephone calls will be accepted at number

.m.

each month for room, board, miscellaneous expenses to be paid at month’s

end.

beginning.

Other:

3. Financial support will be made by me as follows:

Health insurance coverage through

Policy numbers are

School lunch money, clothing, supplies.

Car insurance.

I will pay for counseling.

I will pay for transportation to and from visits.

I will provide food for my child as follows:

I will pay for babysitting as follows:

Other:

Limited Guardianship Placement Plan
Page 3 of 3

(4/22)

Case No.

I graduate

incarcerated.

from high school.

my child graduates

on parole/probation.

4. My plan is for the limited guardianship to continue until:

The end of the current school year.

I am able to provide a drug-free household.
I complete parenting classes.
I am no longer
I am gainfully employed.
I have established myself in a new residence.
I have successfully completed drug or alcohol inpatient/outpatient treatment.
I have cooperated with a substance abuse assessment and have followed the recommendations of the assessment.
I have cooperated with a psychological evaluation and have followed the recommendations of the assessment.
I have successfully completed psychological counseling.
My child can accept my parental authority.
I complete my
I no longer cohabitate with individuals.
I cooperate with a domestic assault program.
I have health insurance coverage for my child.
I have completed my obligation to the Reserves or Armed Forces.
Other:

job training.

G.E.D.

5. I also agree as follows:

As a custodial parent of the minor, I understand that if I substantially fail, without good cause, to follow this plan,
my parental rights may be terminated by the court through proceedings under the juvenile code.

Name of custodial parent (type or print)

City, state, zip Telephone no.

AGREEMENT AND ACCEPTANCE OF APPOINTMENT BY LIMITED GUARDIAN

I will serve as limited guardian of the minor. I agree with this plan, and I accept the appointment and agree to file reports
and to perform all duties required by law.

Date

Signature

Address

Date

Signature

Address

Name of proposed guardian (type or print)

City, state, zip Telephone no.

Put DOB and DLN in Ref. No. row 10 on MC 97a.
Date of birth Driver’s license no. or other identification

Put DOB and DLN in Ref. No. row 11 on MC 97a.

Date of birth Driver’s license no. or other identification

Date

Signature

Address

Date

Signature

Address

PC 652, Limited Guardianship Placement Plan

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the Michigan state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from www.courts.michigan.gov/guardianship (2023-03)
Page(s): 3
Fields(s): 138
Average fields per page: 46
Reading Level: Grade 8
LIST Grouping(s): ES-03-00-00-00, FA-00-00-00-00.

Use our Rate My PDF tool to learn more. Go beyond the above insights and learn more about this or any pdf form at RateMyPDF.com, includes: counts of difficult words used, passive voice decetion, and suggestions for how to make the form more usable.

Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

Here are the fields we could identify.

court_address was Court address (0.63 conf)
first_middle_last_name_minor was First middle and last name of minor (0.34 conf)
limited_previously_approved was This plan modifies a limited guardianship placement plan previously approved by the court (0.44 conf)
child_attend_proposed was To enable my child to attend school in the proposed guardians school district (0.38 conf)
provide_health_proposed was To provide health insurance through the proposed guardian (0.43 conf)
incarcerated__1 was I will be or am incarcerated until (0.43 conf)
currently_without_adequate was I am currently without housing adequate for my child (0.43 conf)
unable_care_child_health was I am unable to care for my child because of my health (0.41 conf)
unable_child_mental was I am unable to care for my child because of my mental instability (0.45 conf)
alternative_recommended_services was I desire an alternative to action recommended by child protective services (0.37 conf)
substantial_control_behavior was I have lost substantial control of my childs behavior (0.42 conf)
need_improve_skills was I need to improve my parenting skills (0.39 conf)
physical_needs_food_may was The minors physical needs for food clothing and housing may best be met by the proposed guardian (0.34 conf)
comply_requirement was To comply with the requirement of the (0.35 conf)
other was Other (0.43 conf)
undefined__1 was undefined (0.38 conf)
reserves was Reserves (0.40 conf)
armed_forces was Armed Forces (0.48 conf)
county was County (0.39 conf)
judge was Judge (0.39 conf)
court_telephone was Court telephone no (0.51 conf)
undefined__2 was undefined_2 (0.39 conf)
textbox was textbox200 (0.35 conf)
visit_child_please_day_plan was I will visit my child on please mark each day you plan to visit (0.30 conf)
visit_child was I will visit my child (0.37 conf)
visits_occur was Visits will occur at (0.28 conf)
telephone_contact_take_place was Telephone contact will take place (0.36 conf)
letters_sent was Letters will be sent (0.36 conf)
conference_provided_receive was I will attend my childs school conference provided I receive timely notice of the conference (0.37 conf)
attend_counseling_child was I will attend counseling with my child (0.35 conf)
arrange_positive_child was I will participate in and arrange positive outings with my child (0.37 conf)
provide_transportation_child was I will provide transportation for my child for (0.41 conf)
attend_doctordental_appointments_child_excluding_emergencies was I will attend all doctordental appointments for my child excluding emergencies (0.43 conf)
transportation_responsibility was Transportation to and from visits with my child will be the responsibility of (0.34 conf)
collect_accepted_number was Collect telephone calls will be accepted at number (0.39 conf)
other_2 was Other_2 (0.44 conf)
please_specify_time was from please specify the time (0.36 conf)
to was to (0.43 conf)
times was times each (0.36 conf)
month was month (0.28 conf)
residence was my residence (0.35 conf)
proposed_guardians_residence was the proposed guardians residence (0.41 conf)
undefined__3 was undefined_3 (0.39 conf)
undefined__4 was undefined_4 (0.39 conf)
daily__1 was daily (0.28 conf)
weekly__1 was weekly (0.28 conf)
monthly__1 was monthly (0.28 conf)
undefined__5 was undefined_5 (0.39 conf)
undefined__6 was undefined_6 (0.39 conf)
daily__2 was daily_2 (0.28 conf)
weekly__2 was weekly_2 (0.28 conf)
monthly__2 was monthly_2 (0.28 conf)
undefined__7 was undefined_7 (0.39 conf)
undefined__8 was undefined_8 (0.39 conf)
daily__3 was daily_3 (0.28 conf)
weekly__3 was weekly_3 (0.28 conf)
monthly__3 was monthly_3 (0.28 conf)
undefined__9 was undefined_9 (0.39 conf)
undefined__10 was undefined_10 (0.39 conf)
undefined__11 was undefined_11 (0.39 conf)
undefined__12 was undefined_12 (0.39 conf)
undefined__13 was undefined_13 (0.39 conf)
undefined__14 was undefined_14 (0.39 conf)
undefined__15 was undefined_15 (0.39 conf)
health_insurance_coverage__1 was Health insurance coverage through (0.41 conf)
school_money_supplies was School lunch money clothing supplies (0.35 conf)
car_insurance was Car insurance (0.40 conf)
undefined__16 was undefined_16 (0.39 conf)
pay_counseling was I will pay for counseling (0.49 conf)
pay_transportation_visits was I will pay for transportation to and from visits (0.32 conf)
provide_food_child_follows was I will provide food for my child as follows (0.41 conf)
pay_babysitting_follows was I will pay for babysitting as follows (0.44 conf)
other_3 was Other_3 (0.44 conf)
policy_numbers was Policy numbers are (0.38 conf)
miscellaneous_expenses_paid was each month for room board miscellaneous expenses to be paid at months (0.38 conf)
end was end (0.45 conf)
beginning was beginning (0.39 conf)
undefined__17 was undefined_17 (0.39 conf)
undefined__18 was undefined_18 (0.39 conf)
undefined__19 was undefined_19 (0.39 conf)
week was week (0.37 conf)
m was M (0.30 conf)
tu was Tu (0.46 conf)
w was W (0.30 conf)
th was Th (0.53 conf)
f was F (0.34 conf)
su was Su (0.51 conf)
sa was Sa (0.49 conf)
end_current_school_year was The end of the current school year (0.34 conf)
child_graduates was my child graduates (0.45 conf)
able_provide_household was I am able to provide a drugfree household (0.37 conf)
complete_parenting_classes was I complete parenting classes (0.40 conf)
longer was I am no longer (0.44 conf)
gainfully_employed was I am gainfully employed (0.40 conf)
established_new_residence was I have established myself in a new residence (0.30 conf)
successfully_drug was I have successfully completed drug or alcohol inpatientoutpatient treatment (0.35 conf)
assessment_followed was I have cooperated with a substance abuse assessment and have followed the recommendations of the assessment (0.45 conf)
psychological_followed was I have cooperated with a psychological evaluation and have followed the recommendations of the assessment (0.35 conf)
completed_psychological was I have successfully completed psychological counseling (0.41 conf)
child_accept_parental was My child can accept my parental authority (0.43 conf)
complete was I complete my (0.39 conf)
longer_cohabitate_individuals was I no longer cohabitate with individuals (0.42 conf)
cooperate_domestic_program was I cooperate with a domestic assault program (0.31 conf)
health_insurance_coverage__2 was I have health insurance coverage for my child (0.41 conf)
completed_armed_forces was I have completed my obligation to the Reserves or Armed Forces (0.44 conf)
other_4 was Other_4 (0.44 conf)
incarcerated__2 was incarcerated (0.36 conf)
paroleprobation was on paroleprobation (0.33 conf)
ged was GED (0.33 conf)
job_training was job training (0.36 conf)
undefined__20 was undefined_21 (0.39 conf)
also_agree_follows was 5 I also agree as follows (0.39 conf)
signature_date__1 was Date (1.00 conf)
signature_date__2 was Date_2 (1.00 conf)
name_parent_type_print__1 was Name of custodial parent type or print (0.34 conf)
name_parent_type_print__2 was Name of custodial parent type or print_2 (0.35 conf)
users1_address_line_one was Address (1.00 conf)
address__1 was Address_2 (0.35 conf)
users1_address_line_two was City state zip (1.00 conf)
telephone__1 was Telephone no (0.44 conf)
city_state_zip__1 was City state zip_2 (0.35 conf)
telephone__2 was Telephone no_2 (0.45 conf)
signature_date__3 was Date_3 (1.00 conf)
signature_date__4 was Date_4 (1.00 conf)
name_guardian_type_print__1 was Name of proposed guardian type or print (0.39 conf)
name_guardian_type_print__2 was Name of proposed guardian type or print_2 (0.38 conf)
address__2 was Address_3 (0.35 conf)
address__3 was Address_4 (0.35 conf)
city_state_zip__2 was City state zip_3 (0.35 conf)
telephone__3 was Telephone no_3 (0.45 conf)
city_state_zip__3 was City state zip_4 (0.35 conf)
telephone__4 was Telephone no_4 (0.45 conf)
text__1 was Text3 (0.35 conf)
text__2 was Text4 (0.35 conf)
text__3 was Text5 (0.35 conf)
text__4 was Text6 (0.35 conf)
graduate was I graduate (0.39 conf)
checkbox was checkbox100 (0.35 conf)

We've done our best to group similar variables togther to avoid overwhelming the user.

Suggested Screen 0:

court_address
first_middle_last_name_minor
limited_previously_approved
child_attend_proposed
provide_health_proposed
incarcerated__1
currently_without_adequate
unable_care_child_health
unable_child_mental
alternative_recommended_services
substantial_control_behavior
need_improve_skills
physical_needs_food_may
comply_requirement
other
undefined__1
reserves
armed_forces
county
judge
court_telephone
undefined__2
textbox
visit_child_please_day_plan
visit_child
visits_occur
telephone_contact_take_place
letters_sent
conference_provided_receive
attend_counseling_child
arrange_positive_child
provide_transportation_child
attend_doctordental_appointments_child_excluding_emergencies
transportation_responsibility
collect_accepted_number
other_2
please_specify_time
to
times
month
residence
proposed_guardians_residence
undefined__3
undefined__4
daily__1
weekly__1
monthly__1
undefined__5
undefined__6
daily__2
weekly__2
monthly__2
undefined__7
undefined__8
daily__3
weekly__3
monthly__3
undefined__9
undefined__10
undefined__11
undefined__12
undefined__13
undefined__14
undefined__15
health_insurance_coverage__1
school_money_supplies
car_insurance
undefined__16
pay_counseling
pay_transportation_visits
provide_food_child_follows
pay_babysitting_follows
other_3
policy_numbers
miscellaneous_expenses_paid
end
beginning
undefined__17
undefined__18
undefined__19
week
m
tu
w
th
f
su
sa
end_current_school_year
child_graduates
able_provide_household
complete_parenting_classes
longer
gainfully_employed
established_new_residence
successfully_drug
assessment_followed
psychological_followed
completed_psychological
child_accept_parental
complete
longer_cohabitate_individuals
cooperate_domestic_program
health_insurance_coverage__2
completed_armed_forces
other_4
incarcerated__2
paroleprobation
ged
job_training
undefined__20
also_agree_follows
signature_date__1
signature_date__2
name_parent_type_print__1
name_parent_type_print__2
users1_address_line_one
address__1
users1_address_line_two
telephone__1
city_state_zip__1
telephone__2
signature_date__3
signature_date__4
name_guardian_type_print__1
name_guardian_type_print__2
address__2
address__3
city_state_zip__2
telephone__3
city_state_zip__3
telephone__4
text__1
text__2
text__3
text__4
graduate
checkbox

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The Legal Innovation & Technology Lab's Form Explorer Beta @ Suffolk Law School Last updated 2023-04-02

PC 652, Limited Guardianship Placement Plan

About This Form:

Identified Data Fields:

Create an Interactive Version of this Form:

The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02