Approved, SCAO

STATE OF MICHIGAN

JUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY

CONSENT TO ADOPTION BY PARENT

JIS CODE: PCS, TCS,
and MiCOURT - CAP

FILE NO.

In the matter of

Full name of child

NOTE:  If the child is an Indian child, use form PCA 308-I.

1. I,

Name

, am the

mother (Date of birth
(Date of birth
father

of the child named above, who was born

Date

at

Place

2. A judge or referee of the court, or other authorized person, has fully explained to me my legal rights as a parent and that I do not
have to sign this consent to adoption.  I understand my parental rights and that if I do sign this consent, I voluntarily and permanently
give up all my parental rights to my child for adoptive placement with

a. the petitioner(s), who filed a petition for the adoption of the adoptee and whose name(s) is/are unknown because identifying

   , adoptee

    )
    )

   .

information is not being exchanged.

b.

Name(s) of petitioner(s)

3. I understand my right to request a rehearing or to appeal within 21 days after an order is entered terminating my parental rights.

4. I have not received or been promised any money or anything of value for the consent to adopt my child except for charges and

, who filed a petition for adoption of my child.

fees approved by the court.

child by the petitioner(s).

confirmed.

5. Of my own free will, I give up completely and permanently my parental rights to my child, and I consent to the adoption of my

6. I understand that my parental rights may be reinstated without further hearing if the adoption of the child named above is not

Date

Address

Date

Address

Parent signature

Parent name (type or print)

The parent signing this consent is an unemancipated minor.  I am the

of the minor parent, and I join with the minor parent in signing this consent.

City

 State

       Zip

parent
guardian (Copy of letters of authority attached.)
guardian ad litem (Copy of order attached.)

Parent/guardian/guardian ad litem of unemancipated minor signature

City

 State

       Zip

See second page for certification by judge/referee
and special acknowledgment for consents by those in the armed services or in prison.

Do not write below this line - For court use only

PCA 308   (2/15)   CONSENT TO ADOPTION BY PARENT

MCL 710.22, MCL 710.43, MCL 710.44, MCL 710.54,  25 USC 1913(a), MCR 3.801

NOTE:  Before taking the consent, the court shall
obtain  from  the  parent(s)  all  the  nonidentifying
information required by MCL 710.27.

CERTIFICATION BY JUDGE/REFEREE

An investigation of this consent has been made.   At a hearing where a verbatim record of testimony was made, I explained to the
parent her/his legal rights and that by signing this consent, s/he was voluntarily and permanently giving up her/his parental rights to
the child for adoption by the petitioner(s).  The parent then voluntarily signed this consent before me.

The parent, guardian, or guardian ad litem of the unemancipated minor parent was present during this hearing and voluntarily
signed this consent before me.

NOTE:  The following direction is necessary only if the consent is signed before another judge of the family division of the circuit court in Michigan
(MCL 710.44[1]).  In other cases, see MCL 710.44(2),(4).

I direct that the consent of

be signed before the judge of

Judge/Referee

Bar no.

County, Michigan or his/her designated referee.

Judge/Referee

Bar no.

Date

Date

In addition to completing the other side of this consent, if the parent signing this consent is in the armed services or is in prison, the
following special acknowledgment must be completed by a person authorized by law to administer oaths.

SPECIAL ACKNOWLEDGMENT

I certify and acknowledge that

Name of parent

is presently

confined

stationed

at

Name of place

 is personally known to me,

  located at

 and stated

Address

City

State

Zip

that s/he is the

mother

father

of the child.  I fully explained her/his legal rights as a parent, that s/he did not

have to sign this consent to adoption, and that if s/he did sign this consent, s/he would be voluntarily and permanently giving up her/

his parental rights to the child for purposes of adoption.  I also explained her/his right to a rehearing or to appeal within 21 days

after an order is entered terminating her/his parental rights.  The parent then voluntarily signed this consent.

Subscribed and sworn to before me on

Date

,

County and state

   .

My commission expires:

Date

Signature:

Notary public, State of Michigan, County of

Notary  Public:

Name (type or print)

Address

City, state, zip