Approved, SCAO

STATE OF MICHIGAN

JUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY

CONSENT TO ADOPTION BY ADOPTEE

JIS CODE:  CAC

FILE NO.

In the matter of

Full name

1. I understand that my consent is necessary for this adoption.

DOB:

   , adoptee

2. The judge or referee of the court has fully explained to me that I do not have to sign this consent.

3. I consent to my adoption by

Name

and

Name

and I consent to taking the above permanently as my legal parent(s), as though parent(s) by birth.

4. I understand that I shall no longer be an heir of my former parent(s), whose rights have been terminated, except if this is a step-
parent adoption, in which case I remain an heir of my biological parent whose rights were terminated, and I also become an heir
of my adopting parent.

5. I agree that following adoption my name will be

    .

Date

Adoptee  signature

Adoptee name (type or print)

Address

City, state, zip

After the court made the investigation it deemed necessary, I fully explained to the adoptee the fact that s/he was consenting to acquire

permanently the adopting parents as legal parents as though the adoptee had been born to the adopting parents, and consenting

to the termination of right to be an heir at law of his/her former parent(s) whose rights have been terminated.* The adoptee then

voluntarily signed this consent before me.  A verbatim record of testimony was made.

Date

Judge/Referee

Bar no.

*In adult adoptions, see current law in MCL 710.60.

Do not write below this line - For court use only

PCA 307   (2/15)   CONSENT TO ADOPTION BY ADOPTEE

MCL 710.43, MCR 3.801