In the matter of 

Petitioner

                     

 
1. I am pregnant out of wedlock and intend to release the expected child for adoption or to consent to the child’s adoption.

           

  

2. The approximate date of conception was 

Date

Location, including city, county, and state

 

 

3. The name and address of the putative father of my expected child is * 

Name (type or print)

Address                                                                                                           City                                                                   State                            Zip

4. I request the court to notify the putative father about his rights to file a notice of intent to claim paternity by issuing and
  serving upon him a notice of intent to release or consent.

 at the following location:

I declare that this petition has been examined by me and that its contents are true to the best of my information, knowledge, 
and belief.

 

                     

Attorney signature

 
Attorney name (type or print)                                                            Bar no.

Name (type or print)

Address

Address

Date

Signature of petitioner

 

 

 

City, state, zip                                                                        Telephone no.

City, state, zip                                                                              Telephone no.

 .

 

*The petition may include more than one putative father where circumstances warrant it.

Do not write below this line - For court use onlyPCA 313 (6/18) EX PARTE PETITION TO ISSUE NOTICE OF INTENT TO RELEASE OR CONSENTMCL 710.33, MCL 710.34, MCR 3.801Approved, SCAO JIS CODE: DNRSTATE OF MICHIGANJUDICIAL CIRCUIT - FAMILY DIVISIONCOUNTYEX PARTE PETITION TO ISSUE NOTICE OFINTENT TO RELEASE OR CONSENTFILE NO.