The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02

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Here is the text we could read:

Approved, SCAO

STATE OF MICHIGAN

JUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY

In the matter of adoptee

Full name of child

STATEMENT OF SERVICES
PERFORMED BY AGENCY/
DEPARTMENT OF HUMAN SERVICES

7-DAY

21-DAY

FILE NO.

DOB:

JIS CODE:  VSD

I state that the following list itemizes the services performed and any fee, compensation, or other thing of value received by or agreed
to be paid to the child-placing agency or the Michigan Department of Human Services for, or incidental to, the adoption of the child.
(NOTE:  If no fee, compensation, or other thing of value is paid or agreed to be paid, you must write "NONE" in the fee column.)

  Date

Service Performed

Fee, Compensation, or Other Value

SUBTOTAL from 7-Day Statement of Services Performed by Agency

The child-placing agency or Michigan Department of Human Services has not requested or received any compensation for the
activities described in MCL 710.54(2).

I am a representative of the child-placing agency/Michigan Department of Human Services and have authority to make this
statement. I declare that this statement has been examined by me and that its contents are true to the best of my information,
knowledge, and belief.

TOTAL

Date

Signature of child-placing agency/DHS representative

NOTE:  Attach this statement to form PCA 347,
"Petitioner's Verified Accounting"

Name (print or type)

Name of agency (print or type)

Address

City, state, zip

Do not write below this line - For court use only

Telephone no.

PCA 345   (9/07)   STATEMENT OF SERVICES PERFORMED BY AGENCY/DEPARTMENT OF HUMAN SERVICES

MCL 710.54(7)

Statement of Services Performed by Agency/Department of Human Services

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the Michigan state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from www.courts.michigan.gov/adoptions-court-forms (2023-03)
Page(s): 1
Fields(s): 51
Average fields per page: 51
Reading Level: Grade 8
LIST Grouping(s): Unknown

Use our Rate My PDF tool to learn more. Go beyond the above insights and learn more about this or any pdf form at RateMyPDF.com, includes: counts of difficult words used, passive voice decetion, and suggestions for how to make the form more usable.

Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

Here are the fields we could identify.

cirno was cirno (0.60 conf)
county was county (0.39 conf)
docket_number was caseno (1.00 conf)
casename was casename (0.35 conf)
users1_birthdate was dob (1.00 conf)
signature_date__1 was date1 (1.00 conf)
service__1 was service1 (0.35 conf)
fee__1 was fee1 (0.35 conf)
none__1 was none1 (0.35 conf)
signature_date__2 was date2 (1.00 conf)
service__2 was service2 (0.35 conf)
fee__2 was fee2 (0.35 conf)
none__2 was none2 (0.35 conf)
signature_date__3 was date3 (1.00 conf)
service__3 was service3 (0.35 conf)
fee__3 was fee3 (0.35 conf)
none__3 was none3 (0.35 conf)
signature_date__4 was date4 (1.00 conf)
service__4 was service4 (0.35 conf)
fee__4 was fee4 (0.35 conf)
none__4 was none4 (0.35 conf)
signature_date__5 was date5 (1.00 conf)
service__5 was service5 (0.35 conf)
fee__5 was fee5 (0.35 conf)
none__5 was none5 (0.35 conf)
signature_date__6 was date6 (1.00 conf)
service__6 was service6 (0.35 conf)
fee__6 was fee6 (0.35 conf)
none__6 was none6 (0.35 conf)
signature_date__7 was date7 (1.00 conf)
service__7 was service7 (0.35 conf)
fee__7 was fee7 (0.35 conf)
none__7 was none7 (0.35 conf)
signature_date__8 was date8 (1.00 conf)
service__8 was service8 (0.35 conf)
fee__8 was fee8 (0.35 conf)
none__8 was none8 (0.35 conf)
signature_date__9 was date9 (1.00 conf)
service__9 was service9 (0.35 conf)
fee__9 was fee9 (0.35 conf)
none__9 was none9 (0.35 conf)
fee__10 was fee10 (0.35 conf)
total was total (0.32 conf)
sdate was sdate (0.35 conf)
users1_name was name (1.00 conf)
agency was agency (0.54 conf)
users1_address_line_one was address (1.00 conf)
users1_address_city was city (1.00 conf)
telno was telno (0.35 conf)
check_box__1 was Check Box1 (0.52 conf)
check_box__2 was Check Box2 (0.37 conf)

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The Legal Innovation & Technology Lab's Form Explorer Beta @ Suffolk Law School Last updated 2023-04-02

Statement of Services Performed by Agency/Department of Human Services

About This Form:

Identified Data Fields:

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The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02