1. The minor is an Indian child as defined in MCR 3.002(12) and either is eligible to be placed for adoption or presently is in an 
  adoptive placement.

 , am the child’s natural father and ask that my identity be 

 , am the child’s natural mother and ask that my identity 

In the matter of 

Full name of child

 

    kept confidential.

 2. I, 

Name

 3. I, 

Name

    be kept confidential.

 

 

                     

Subscribed and sworn to before me on 

 County, Michigan.

My commission expires: 

Date

 Signature: 

Deputy clerk/Notary public

Notary public, State of Michigan, County of 

Date

 

Signature

 , 
  

PCA 353 (6/17) REQUEST FOR CONFIDENTIALITY25 USC 1951(a)Do not write below this line - For court use onlyApproved, SCAO Original - Court1st copy - Secretary of Interior2nd copy - MDHHS Central Adoption Registry                                JIS CODE: RQCSTATE OF MICHIGANJUDICIAL CIRCUIT - FAMILY DIVISIONCOUNTY REQUEST FOR CONFIDENTIALITYFILE NO.Court addressCourt telephone no.

PCA 353, Request for Confidentiality

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About This Form:

• Sourced from www.courts.michigan.gov/adoptions-court-forms (2023-03)
• Page(s): 1
• Fields(s): 14
• Average fields per page: 14
• Reading Level: Grade 12
• LIST Grouping(s): FA-00-00-00-00.

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