Approved, SCAO

STATE OF MICHIGAN

JUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY

In the matter of

Full name of child

1. I,

Name

the child named above.

CONSENT TO ADOPTION BY GUARDIAN

JIS CODE:  CAG

FILE NO.

   , adoptee

the parent of the child named above.

   .

             Court. (A copy of the

, am the court-appointed guardian for

The child named above was born

Date

     at

Place

2. I have authority to consent to this adoption by order of the

order is attached and a copy of my current letters of guardianship are attached.)

3.

a. A judge or referee of the court, other authorized person, has fully explained to me my legal rights as guardian and the legal
rights of the parent(s) of the child named above and that I do not have to sign this consent.  I understand that if I do sign this
consent, my rights as guardian and the legal rights of each parent will be terminated and the child will be placed with:
(See b.i. and b.ii. below.)

b. A judge or referee of the court, or other authorized person, has fully explained to me, as guardian of the parent, the legal rights
of the parent to the child named above and that I do not have to sign this consent.  I understand that if I do sign this consent,
I voluntarily and permanently give up, on behalf of the parent, his/her parental rights, and the child will be placed with:
(See i and ii below.)
i.

the petitioner(s), who filed a petition for the adoption of the adoptee and whose name(s) is/are unknown because
identifying information is not being exchanged.

ii.

     , who filed a petition for adoption of the adoptee.

4. I have not received or been promised any money or anything of value for the consent to adopt the child named above, except for

charges and fees approved by the court.

5. I understand my rights as guardian and the rights of the parent(s) to the child and the right to request a rehearing or to appeal

within 21 days after an order is entered terminating the rights of the parent(s) and of myself as guardian.

6.

a. As guardian of the child named above, I voluntarily and permanently give up my rights as guardian and the rights of each

parent to the child named above and consent to the adoption by the petitioner(s).

b. As guardian of the parent and on his/her behalf, I voluntarily and permanently give up his/her parental rights to the child

named above and consent to the adoption by the petitioner(s).

Date

Address

Guardian signature

Guardian name (type or print)

See reverse side for certification by judge/referee

City

 State

       Zip

Do not write below this line - For court use only

PCA 308a   (2/15)   CONSENT TO ADOPTION BY GUARDIAN

MCL 700.5215(e), MCL 710.22, MCL 710.43,
MCL 710.44, MCL 710.54, 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

a. the guardian of the child his/her legal rights and that by signing this consent, the guardian was voluntarily and permanently

giving up his/her rights to the child for adoption by the petitioner(s).

b. the guardian of the parent the parent's legal rights and that by signing this consent, the guardian was voluntarily and
permanently giving up, on behalf of the parent, his/her parental rights to the child for adoption by the petitioner(s).

The guardian then voluntarily signed this consent before me.

Judge/Referee

Bar no.

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

Name of guardian

be signed before the judge of

County, Michigan or his/her designated referee.

Judge/Referee

Bar no.

Date

Date