Approved, SCAO

STATE OF MICHIGAN

JUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY

NOTICE OF INTENT
TO RELEASE OR CONSENT

JIS CODE:  NIR

FILE NO.

NOTE:  Personal service of this form is required 30 days before the expected date of confinement.

In the matter of

Petitioner

TO:

TAKE NOTICE:  The woman named above has filed an ex parte petition with this court which alleges that:

1. She is pregnant out of wedlock and intends to release the expected child for adoption or to consent to the child's adoption.

2. The approximate date of conception was

     at the following location:

3. Her expected date of confinement is
4. You are the putative father of the expected child.

YOU ARE NOTIFIED AND INFORMED:

.

5. You have a right to file a notice of intent to claim paternity before the birth of the child with the family division of the circuit court

in any county of this state on a form available at this court.

6. If you file a notice of intent to claim paternity, you shall be entitled to notice of any hearing involving that child to determine the

identity of the father of the child and any hearing to determine or terminate his paternal rights to this child.

7. YOUR FAILURE TO FILE a notice of intent to claim paternity before the expected date of confinement or before the birth of the
child, whichever is later, is a waiver of your right to receive notice of the hearing and is a denial of your interest in custody of the
child, which WILL RESULT IN THE COURT'S TERMINATION OF YOUR RIGHTS TO THE CHIILD.

Deputy clerk

PROOF OF PERSONAL SERVICE

at

at

Time

Location

  , I personally served a copy of this notice on

    .

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

Date

On

Date

Name

Date

Signature of peace officer/court authorized person

Do not write below this line - For court use only

PCA 314   (9/07)   NOTICE OF INTENT TO RELEASE OR CONSENT

MCL 710.34, MCR 3.801, MCR 3.802