Approved, SCAO

STATE OF MICHIGAN

JIS CODE:  ACF

FILE NO.

JUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY

PETITION AND ORDER FOR APPROVAL OF
CONFIDENTIAL INTERMEDIARY FEE

In the matter of

Full name of child

PETITION

   , adoptee

1. I was appointed by the court to serve as a confidential intermediary to search for and to contact
an adult child of the adoptee.

a former family member of the adoptee.

the adoptee.

2. Services have been rendered and expenses incurred while acting as the court-appointed confidential intermediary.
3. Except for actual expenses incurred in performing services, I have not requested nor accepted any money or thing of value

for serving as the confidential intermediary.

4. The expenses incurred, the nature of services rendered, and the fee for services are:  (attach additional sheets if needed)

5. I REQUEST that the court allow the fee.

Date

Signature of petitioner

Name of petitioner (type or print)

Address

City, state, zip

CONSENT / OBJECTION

6. The court appointed the petitioner as my confidential intermediary.  I have received and reviewed the above petition for

approval of the fee.

I consent to the fee and waive the hearing on this petition.
I object to the fee and request a hearing on this petition.

Telephone no.

Bar no.

Date

7. Date of hearing:

Signature

Name (type or print)

ORDER

Judge:

8. Notice of hearing has been given to or waived by the interested parties.

9. The fee requested in the petition is reasonable and is approved except:

Date

Judge

Do not write below this line - For court use only

PCA 343   (2/15)   PETITION AND ORDER FOR APPROVAL OF CONFIDENTIAL INTERMEDIARY FEE

MCL 710.68b