PETITION FOR RESCISSION OF
ADOPTION AND ORDER

JIS CODE:  PFR

FILE NO.

Approved, SCAO

STATE OF MICHIGAN

JUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY

In the matter of

Full name of child at birth

1. I,

2. I,

Adoptee's present name

Birth parent's name

Full name of child immediately after adoption

Birth date

was adopted by

Stepparent's name

, birth parent, had my parental rights terminated by order of this court.

3. I desire to rescind the adoption by the stepparent and restore the parental rights of the birth parent.

4. A copy of my new live birth certificate is attached.

5. The adoptee's name will be

6. The adoptee's legal parents are:

First

Middle

Last

Name  of natural parent

Name  of adoptive stepparent

Address

Telephone no.

City, state, zip

Telephone no.

7. I REQUEST that the court conduct a hearing, and an investigation if necessary, and enter an order of rescission of the adoption

and restore the parental rights of the petitioner birth parent.

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

/s/
Signature of adoptee petitioner

Address

City, state, zip
/s/
Signature of birth parent petitioner

Address

City, state, zip

Attorney name (type or print)

City

State

Zip

 Telephone no.

(SEE SECOND PAGE)

Do not write below this line - For court use only

   , adoptee

    .

    .

Telephone no.

Telephone no.

Bar no.

Address

City, state, zip

Date

Date

/s/
Attorney signature

Address

PCA 349   (2/15)   PETITION FOR RESCISSION OF ADOPTION AND ORDER

MCL 710.66

8. The adoption of the adoptee named above by the stepparent named above is rescinded. The parental rights of the

IT IS ORDERED:

birth parent named above are restored.

9. The petition is denied.

Date

Judge

Bar no.