Approved, SCAO

STATE OF MICHIGAN

JUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY

In the matter of

Full name of child

STATEMENT OF PARENT/GUARDIAN
 AUTHORIZING TEMPORARY PLACEMENT OF
CHILD FOR ADOPTION

1. I have legal and physical custody of the child as

mother.

father.

guardian pursuant to an order issued by the

Name of court

2. I authorize

OR

temporary placement of the child with prospective adoptive parents in accordance with the Michigan Adoption Code, and

a. I have 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 parent(s) of an adoptee.

b. I have been informed that the child-placing agency must give me an opportunity to review the preplacement assessment

of the prospective adoptive parent(s) before any temporary placement.

3. I have been informed that I retain full parental rights to the child and that the agency must file a petition on my behalf if I wish

to regain custody of my child during the temporary placement in the adoptive home.

JIS CODE:  ATA

FILE NO.

DOB:

, adoptee

court.  (Copy of order is attached.)

, a child-placing agency, to make a

Date
/s/
Signature of parent/guardian

Name of parent/guardian (print)
/s/
Signature of parent/guardian

Name of parent/guardian (print)

/s/
Signature of witness

Name of witness (print)
/s/
Signature of witness

Name of witness (print)

CERTIFICATION BY PARENT/GUARDIAN OF UNEMANCIPATED MINOR PARENT

I certify that I am the
who is an unemancipated minor parent of the child.  I join with the parent in authorizing the child-placing agency to make a
temporary placement of the child with the prospective adoptive parents.

legal guardian

parent

of

Date
/s/
Signature of parent/guardian

/s/
Signature of witness

Name of parent/guardian (print)

Name of witness (print)

Address

City

State

Zip

Do not write below this line - For court use only

PCA 329   (2/15)   STATEMENT OF PARENT/GUARDIAN AUTHORIZING TEMPORARY PLACEMENT

OF CHILD FOR ADOPTION

MCL 710.23b, MCL 710.23d