, adoptee

 born on

 .

 .

 , am the mother of 

Child’s name at birth

Street address                                                                                       City, county, state, zip

 at 

City, county, state

 .

In the matter of 

Full name of child

Mother’s full legal name

2. I reside at 

Date

1. I, 

   

3. My date of birth is 

Date

4. Indian Child Status

  a. Are you a member of a federally recognized American Indian tribe or Alaskan Native Village or eligible to enroll in any such
 

    tribe or village? 

 Unknown

 Yes 

 No 

  b. Is anyone in your family a member of a federally recognized American Indian tribe or Alaskan Native Village or eligible to
 

    enroll in any such tribe or village? 

 Unknown

 Yes 

 No 

  c.  Is the father of the child a member of a federally recognized American Indian tribe or Alaskan Native Village or eligible to 
 

    enroll in any such tribe or village? 

 Unknown

 Yes 

 No 

  d. Is anyone in the father’s family a member of a federally recognized American Indian tribe or Alaskan Native Village or  
 

    eligible to enroll in any such tribe or village? 

 Unknown

 Yes 

 No 

5. Legal Status of Child to be Adopted

  a. Has any man served you with a paternity action regarding the child? 

 Yes 

 No

  b. Has any court entered an order naming the father of the child? 

 Yes 

 No

  c.  Have you signed an acknowledgement of parentage with the child’s father? 

 Yes 

 No

6. Marital Status of Mother

  a. Were you married to a man at the time of conception or time of birth of the child? 
 

    6b. If No, complete item 7.

 Yes 

 No 

If Yes, answer question 

  b. Please provide the following information about your husband:

  1) His full legal name: 
 

  2) His date of birth: 

 

  3) His address: 

 

  4) His telephone number: 

  5) His e-mail address: 

 

 

 

 

 

 

 

 

  6 ) Is your husband the biological father of the child? 

 Yes 

 No 

If No, complete item 7.

 

PCA 356 (6/17) VERIFIED DECLARATION ABOUT PATERNITY (OUT-OF-COURT RELEASE OR CONSENT)Approved, SCAOSTATE OF MICHIGANJUDICIAL CIRCUIT - FAMILY DIVISIONCOUNTY VERIFIED DECLARATION ABOUT PATERNITY (OUT-OF-COURTRELEASE OR CONSENT)FILE NO.Note: For use in non-Indian child adoptions onlyMCL 710.36(6), MCL 710.37Verified Declaration About Paternity

 

(6/17) Page 
 

  

 of 

  

 7. Identification of Child’s Father
  Note: Attach a separate addendum for each possible father.

File No. 

 

 

a. Do you know the father’s name and how to locate him?
 
  PCA 356a). If No, complete item 7b.

 Yes

 

 No If Yes, complete and attach Addendum A (form 

 

 

b. Do you know the father’s name, but not how to locate him?
  PCA 356b). If No, complete and attach Addendum C (form PCA 356c). 

 Yes

 

 

 No If Yes, complete and attach Addendum B (form 

 

I declare that the statements above and on the attached addendums are true to the best of my information, knowledge, and 
belief.

     

 

 

Date

Date

 

 
 
 

                     

                     

                     

Mother’s signature

 

 

 

 

 

Attorney’s signature                                                                                   

Attorney’s name (type or print)  

 

Address

Bar no.

 

City, state, zip                                                                        Telephone no.