Approved, SCAO

STATE OF MICHIGAN

JIS CODE:  SAC

FILE NO.

JUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY

STATEMENT TO ACCOMPANY CONSENT
IN DIRECT PLACEMENT

In the matter of

Full name of child

DOB:

, adoptee

1. I am the parent or guardian of the adoptee and I intend to consent to a direct placement of the adoptee.

2. I have received a list of adoption support groups.

3. I am being assisted by a child-placing agency.  I have received a copy of the written document described in MCL 722.956(1)(c).

4.

I have received counseling related to this adoption.

I waive counseling related to this adoption.

5. I have not received or been promised any money or anything of value for the consent to the adoption, except for lawful payments

as itemized on the verified accounting filed with the consent.

6. The validity and finality of my consent is not affected by any collateral or separate agreement between myself and the adoptive

parent(s).

7. I understand that the welfare of the adoptee is served if the parent keeps the child-placing agency or Michigan Department of

Health and Human Services informed of any health problems that the parent develops that could affect the adoptee.

8. I understand that the welfare of the adoptee is served if I keep my address current with the child-placing agency or Michigan
Department of Health and Human Services in order to permit a response to any inquiry concerning medical or social history from
an adoptive parent of a minor adoptee or from an adoptee who is 18 years or older.

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

Date

Signature of parent or guardian

Name of parent or guardian (print)

Address

City, state, zip

Telephone no.

CERTIFICATION BY PARENT/GUARDIAN OF UNEMANCIPATED MINOR PARENT

I certify that I am the

parent

legal guardian

of

    ,

Name of parent of child

who is an unemancipated minor parent of the child.  I have reviewed this statement and agree with the placement.

Date

Signature  of  parent/guardian

Name of parent/guardian (print)

Address

City, state, and zip

Signature  of  witness

Name  of  witness  (print)

Do not write below this line - For court use only

PCA 339   (2/15)   STATEMENT TO ACCOMPANY CONSENT IN DIRECT PLACEMENT

MCL 710.44(5)