Approved, SCAO

STATE OF MICHIGAN

JUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY

In the matter of

Full name of child

STATEMENT OF CHILD-PLACING AGENCY
TRANSFERRING PHYSICAL CUSTODY OF
CHILD FOR ADOPTION

FILE NO.

DOB:

JIS CODE: CTC

1. I am a representative of the child-placing agency and make this statement on behalf of the agency.

2. The agency is making a temporary placement of the child in a prospective adoptive home as authorized by the parent(s) or

guardian(s) of the child.  (copy of authorization attached)

3. On

Date

prospective adoptive parent(s)

Name(s) of parent(s)

County at

Street  address

, for the purpose of adoption, physical custody of the child was transferred to the

       who reside(s) in

City

    .

Zip

4. The parent(s) or guardian(s) having legal custody of the child retain full parental rights to the child.  This temporary placement
may be revoked by the agency filing a petition in this court on behalf of the parent(s) or guardian(s) requesting that the child be
returned to the parent(s) or guardian(s).

5. The agency has read the preplacement assessment of the prospective adoptive parent(s) that was completed or updated less
than a year ago and that states that the prospective adoptive parent(s) are suitable to be adoptive parent(s).  The child-placing
agency has given the parent or guardian who authorized temporary placement an opportunity to review the preplacement
assessment.

6. The names and addresses of the mother and father are:

She is a minor.  The name and address of the minor mother's parent or guardian who agreed with the placement are

Street address

City

State

Zip

City

State

Zip

Street address

City

State

Zip

He is a

legal

putative father of the child.

He is a minor.  The name and address of the minor father's parent or guardian who agreed with the placement are

Mother:

Name

Name(s)

Street address

Father:

Name

Name(s)

Street address

.

.

City

State

Zip

(SEE SECOND PAGE)

Do not write below this line - For court use only

PCA 331   (2/15)   STATEMENT OF CHILD-PLACING AGENCY TRANSFERRING PHYSICAL CUSTODY OF CHILD FOR

ADOPTION

MCL 710.23d

6. continued

The name and address of each other possible putative father is

.

Date

Signature of agency representative

Name of agency representative (print)

Signature of witness

Name of witness (print)

REPORT TO COURT FOLLOWING TEMPORARY PLACEMENT

I report that I am a representative of the agency authorized to make this report.  The agency has been authorized by the parent
or guardian to make the temporary placement of the child in the home of the prospective adoptive parent(s) set forth in the above
statement.  The statement of prospective adoptive parent(s) evidencing transfer of physical custody of the child to them and the
authorization (form PCA 329) is attached.

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

Date

Signature of agency representative

Name of agency representative (print)

Address

Name of agency

City, state, and zip