Approved, SCAO

STATE OF MICHIGAN

JUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY

In the matter of

Full name of child

ORDER FOR BLOOD OR TISSUE TYPING
OR DNA PROFILE
(SAFE DELIVERY OF NEWBORN ACT)

JIS CODE:  OTT

FILE NO.

          , a surrendered newborn child

1. Date of hearing:

2. Alleged parent(s),

Name(s) of petitioner(s)

Judge:

filed a petition for custody of the surrendered newborn child.  Testing to determine whether the individual(s) is/are the biological
parent(s) is required before the hearing on the petition.

3. The newborn child was surrendered to an emergency service provider and a petition for custody of the child was filed within 28

4. The petitioner claims to be the biological

mother

father of the surrendered newborn child.

5. The petitioner is indigent and unable to pay for the cost of testing.

THE COURT FINDS:

days after the surrender.

IT IS ORDERED:

6. The petitioner(s),

Name(s) of petitioner(s)

Bar no.

    ,

    ,

and the surrendered newborn child shall have a blood or tissue typing or DNA profile conducted to determine whether he/she
is likely to be or is not the biological parent of the child.

7. The petitioner(s) and the child shall  appear at the location designated and on the date and time set as notified by the child-placing

agency,

Name(s) of agency(ies)

.

8. Payment for the tests must be made as follows:

Payment for the tests was waived because of indigency.

9. In accordance with MCL 722.716, the blood or tissue typing or DNA-identification profiling shall be conducted by a person

accredited for paternity or maternity determination by a nationally recognized scientific organization, including, but not limited
to, the American Association of Blood Banks, and a report of the results shall be submitted to the child-placing agency.

10. The result of blood or tissue typing or DNA-identification profiling and the summary report shall be filed with the court and served

by the child-placing agency on the individuals.

11. At the time of serving the results and summary upon the alleged parent(s), the child-placing agency shall also serve written
notice that objection to the DNA-identification profiling or the summary report is waived unless specific objections are made
in writing within 14 calendar days after service of the notice and delivered to the court at the address specified in the notice.
12. Refusal or failure to submit to the typing or DNA-identification profiling may result in a dismissal of the custody action in addition

to other remedies available to the court.

Date

Judge

Do not write below this line - For court use only

CCFD 04   (9/07)   ORDER FOR BLOOD OR TISSUE TYPING OR DNA PROFILE (SAFE DELIVERY OF NEWBORN ACT)

MCL 712.11, MCL 712.12, MCL 722.716