Approved, SCAO

JIS CODE: SNR

STATE OF MICHIGAN

JUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY

STATEMENT OF NONRESIDENT
PROSPECTIVE ADOPTIVE PARENT
TRANSFERRING PHYSICAL CUSTODY OF
CHILD FOR ADOPTION

In the matter of

Full name of child

1. Physical custody of the child was transferred to me on

FILE NO.

DOB:

.

Date

State

.

2. I am a prospective adoptive parent and a resident of

.  I agree to obtain approval in

compliance  with the Interstate Compact on Placement of Children before the child is sent, brought, or caused to be sent or

brought into

3. Temporary domicile is in

City, state, and zip

.  I agree to submit to the jurisdiction of the State of Michigan.

County, Michigan at

Address

4. The temporary placement will not become formal until both parents consent to adoption or release their parental rights and

the court orders the termination of parental rights of both parents and approves the placement.

5. I understand if the court enters an order directing return of the child to the parent or guardian with legal custody, I must return

physical custody of the child to the parent or guardian named in the order within 24 hours of being served with the court order.

Date

Signature of prospective adoptive parent

Signature of witness

Name of prospective adoptive parent (print)

Name of witness (print)

Signature of prospective adoptive parent

Name of prospective adoptive parent (print)

Address

City, state, and zip

Do not write below this line - For court use only

PCA 332a   (2/15)   STATEMENT OF NONRESIDENT PROSPECTIVE ADOPTIVE PARENT TRANSFERRING PHYSICAL

CUSTODY OF CHILD FOR ADOPTION

MCL 710.23d