Approved, SCAO

STATE OF MICHIGAN

JUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY

ORDER AFTER HEARING ON PETITION TO
ACCEPT RELEASE AND TERMINATE RIGHTS
TO SURRENDERED NEWBORN CHILD

JIS CODE:  TSN

CASE NO.

2. A petition requesting an order to accept the release of the surrendering parent and terminating the parental rights of both the

In the matter of

Full name of child

1. Date of hearing:

Judge:

surrendering and nonsurrendering parents has been filed by
a child-placing agency.

Name of agency

THE COURT FINDS by a preponderance of the evidence that:

 , a surrendered newborn child

Bar no.

    ,

3. The surrendering parent,

the newborn.

Name

4.

a. The nonsurrendering parent,

Name

with notice of the surrender of the newborn.

    ,

has

has not

knowingly released

, has been identified and located and provided

b. The nonsurrendering parent has not been identified or located, and the child-placing agency has made reasonable efforts

to provide notice of the surrender of the newborn.

5. The

surrendering parent

nonsurrendering parent

has not filed a petition for custody of the newborn within

the required 28 days following notice of the surrender of the newborn.

IT IS ORDERED:

6. The release of the surrendering parent

is

is not

accepted.

7. The parental rights of the

surrendering parent

nonsurrendering parent

are terminated.  Custody and

care of the surrendered newborn child is granted to

 , a

child-placing agency.  The prior court order dated
the surrendered newborn child with the prospective adoptive parent(s) is continued.

that authorizes placement of

8. The petition is denied.

9. Other:

Date

Judge

Do not write below this line - For court use only

CCFD 08   (9/07)   ORDER AFTER HEARING ON PETITION TO ACCEPT RELEASE AND TERMINATE RIGHTS TO

SURRENDERED NEWBORN CHILD

MCL 712.17