In the matter of 

First and last name(s), alias(es)

I affirm:

1. I have met with or had contact with the child as required by 
 

(specify) 

 

 the court. 

 

 MCL 712A.17d(1)(d).

 

 I did not meet with or observe the child because:

2. I have reviewed the agency case file.

3. Consistent with the Michigan Rules of Professional Conduct, I have consulted with the child’s parent(s) and/or guardian(s),
 

foster care provider(s), and case worker(s).

 4. I am a substitute for the appointed lawyer-guardian ad litem, I have consulted and discussed with the appointed 
    lawyer-guardian ad litem his/her visit with the child, review of the agency case file, and any discussions with the child’s 
    parent(s), guardian(s), foster care provider(s), and case worker(s).

 
 

I understand that I will be paid for the services performed only if I have met with or observed the child before every proceeding
or hearing as required by law.

I declare under the penalties of perjury that this verified statement has been examined by me and that its contents are true 
to the best of my information, knowledge, and belief.

Lawyer-guardian ad litem signature

Address

 

 

Lawyer-guardian ad litem name (type or print)

City, state, zip                                                                            Telephone no.

Approved, SCAO
Form JC 82, Rev. 12/22
MCL 712A.17d, MCR 3.915
Page 1 of 1

STATE OF MICHIGANJUDICIAL CIRCUIT - FAMILY DIVISIONCOUNTYVERIFIED STATEMENT OFSERVICE PERFORMED BYLAWYER-GUARDIAN AD LITEMCASE NO.PETITION NO.JUDGECourt addressCourt telephone no.JIS Code: ASP