Approved, SCAO

STATE OF MICHIGAN

JIS CODE: FTP

FILE NO.

JUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY

FOLLOW-UP REPORT AFTER TEMPORARY
PLACEMENT OF CHILD FOR ADOPTION

In the matter of

Full name of child

DOB:

, adoptee

NOTE:  This report is to be completed within 30 days after the transfer of physical custody of the child.  This report is in addition to the
report included in the statement transferring custody (either form PCA 330 or PCA 331).

1. I am the

adoption attorney

representative of the child-placing agency

that assisted in the temporary placement of

the child named above.

2. On

Date

prospective adoptive parent(s)

Name(s) of prospective parent(s)

County at

Street  address

3. The temporary placement was made by

Name(s) of parent(s)

, for the purpose of adoption, physical custody of the child was transferred to the

       who reside(s) in

City

State

Zip

Street  address

City

State

Zip

4. Since the transfer of physical custody, the following has occurred

a. a petition for adoption was filed by the prospective adoptive parents in

County.

    .

    .

    ,

b. the child was returned to

Name(s)

parent(s).

guardian(s).

child-placing agency.

Date

Date

Signature of adoption attorney

Signature of agency representative

Name (type or print)

Bar no.

Name (type or print)

Firm name

Address

City, state, zip

Agency name

Address

Telephone no.

City, state, zip

Telephone no.

Do not write below this line - For court use only

PCA 333   (2/15)   FOLLOW-UP REPORT AFTER TEMPORARY PLACEMENT OF CHILD FOR ADOPTION

MCL 710.23d(3)