, adoptee 

Name of tribe and identification no. (if one)

 

 , am the 

  mother 
  father 

(Date of birth 

(Date of birth 

 

 

 )
 )

 . 

 .

  of the child named above, who was born 

Date

 at 

Place

. A judge has fully explained to me my legal rights as a parent and that I do not have to sign this consent to adoption. The 
  explanation given to me was in a language understood by me or interpreted into my own language if I do not speak English. 
I understand my parental rights and that if I do sign this consent, I voluntarily and permanently give up all of my parental rights 
 
 
to my child for adoptive placement with
 
 
 

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

 , who filed a petition for adoption of my child.

information is not being exchanged.

 

Name(s) of petitioner(s)

3. This consent constitutes a consent for adoption under MCL 712B.13 and is not given before or within 10 days after the birth 
  of my child. I understand that my consent may be withdrawn for any reason at any time before the entry of a final order of 
  adoption by filing a written demand requesting the return of my child.

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

5. I have not received or been promised any money or anything of value for the release of my child except for charges and fees
  approved by the court.

6. 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 
  child by the petitioner(s). The name and address of the person or entity that will arrange the preadoptive or adoptive placement

Name and address of person or entity that will arrange the preadoptive or adoptive placement

 

 

 

 

 

 

 
 
 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.

  

  

 

 

 

 

 

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

City 

 

State 

 

Zip

Date

Parent/guardian of unemancipated minor signature

Address   

 

 

 

City 

 

State 

 

Zip

See reverse side for certification by judge and statement of interpreter.

Parent signature

Parent name (type or print)

 

 

 

 

 

 

 

 

 

 

 

 

 

Address   
 

 

 

 

is 

   

Date

In the matter of 

Full name of child

 

 

 

 

 

 
 
1. I, 

Name

  2

Approved, SCAOPCS CODE: CIPTCS CODE: CIPDo not write below this line - For court use onlySTATE OF MICHIGANJUDICIAL CIRCUIT - FAMILY DIVISIONCOUNTYCONSENT BY PARENT TOADOPTION OF INDIAN CHILDFILE NO.PCA 308-I (9/17) CONSENT BY PARENT TO ADOPTION OF INDIAN CHILDMCL 710.43, MCL 710.44, MCL 710.54, MCL 712B.13, MCL 712B.27, 25 USC 1913(a), MCR 3.8011. Notice of this proceeding was given as required by MCR 3.802(A)(3), and 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 Indian child for adoption by the 

 
  petitioner(s). The parent then voluntarily signed this consent before me.

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

 

 

Judge  

 

 

Bar no.

  2

Date

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

STATEMENT OF INTERPRETER

I state that this proceeding was interpreted by me to the parent in his/her spoken language of 

Spoken language of parent

 

 

 

 

 

 

 

Subscribed and sworn to before me on 

My commission expires: 

Date

  Signature: 

 

Notary public, State of Michigan, County of 

Date

 

Interpreter signature

 , 

County and state

 , 

Name (type or print)

 .

 . 

Address   

 

 

 

City 

 

 

 

State 

 

Zip

Consent by Parent to Adoption of Indian Child 

(9/17)  Page 

  

 of 

  

File No.