In the matter of 
  
                                                                                                                                                       

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 adult.
 unemancipated minor.

 , an 

 intends to file a petition.
 has filed a petition with the court, stating that

 

 .

 .

a. she is the mother of 

 
Name of child (type or print)

   

 an unborn child expected on or about 

Date

  b. you are the father of the child.

   

 

 

                     

TO: 

 
1. 

Putative father

                     

Name (type or print)

 intends to sign a release or consent relinquishing her rights to the child.
 has joined with her spouse in a petition for adoption.

  c.  she  
 
           
2. The law provides that as a putative father, you have a right to request custody of the child. The law also provides that your
 
 
3. If you do not want to request custody of the child, complete the section below and mail or deliver to
 

failure to appear at the hearing on the petition shall constitute a denial of your interest in the custody of the child, which shall 
result in the court’s termination of your parental rights to the child.

 .

Name and address

CUSTODY STATEMENT OF PUTATIVE FATHER

 I am the father of the child and deny any interest in the custody of the child.
 I may be the father of the child and deny any interest in the custody of the child.
 I am not the father of the child.

1. I voluntarily state: (check one)
    
    
    
2. I give up my right to notice of the time and place of hearing to identify the child’s father and determine or terminate his
    rights.

I declare that this “Custody Statement of Putative Father” has been examined by me and that its contents are true to the
best of my information, knowledge, and belief.

 

Date

Signature of witness

Name of witness

Address   

 

 

 

Signature of putative father

Date

Address

 

 

 

 

 

 

 

 

 

City, state, zip 

 

 

Telephone no.

Signature of parent/guardian/guardian ad litem of minor putative father

City, state, zip 

 

 

 

Telephone no.

Do not write below this line - For court use onlyPCA 316 (6/17) NOTICE TO PUTATIVE FATHER AND CUSTODY STATEMENTMCL 710.36, MCL 710.37, MCR 3.801Approved, SCAO                                 JIS CODE: NPFSTATE OF MICHIGANJUDICIAL CIRCUIT - FAMILY DIVISIONCOUNTY NOTICE TO PUTATIVE FATHERAND CUSTODY STATEMENTFILE NO.