FILE NO.

DOB:

Approved, SCAO

JIS CODE: TCA

STATE OF MICHIGAN

JUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY

STATEMENT OF PARENT/GUARDIAN
TRANSFERRING PHYSICAL CUSTODY OF
CHILD FOR ADOPTION

In the matter of the

Full name of child

1. I am a

parent

guardian with legal and physical custody of the child and am being assisted in the temporary

placement of the child by

Name of adoption attorney or agency

.  (Attach copy of current letters of authority.)

2. On

Date

, for the purpose of adoption, physical custody of the child was transferred to:

a. prospective adoptive parent(s)

Name(s) of parent(s)

County at

Street  address

b. Unknown to me because full identifying information is not being exchanged.

       who reside(s) in

City

    .

Zip

3. I understand that I retain full parental rights to my child.  I agree that the prospective adoptive parent may consent to all medical,

surgical, psychological, educational, and related services for my child during the temporary placement.

4. I understand that this temporary placement may be revoked by me by filing a petition in this court requesting that my child be

5. I have read a preplacement assessment of the prospective adoptive parent(s) that was completed or updated  less than a year

ago and which states that the prospective adoptive parent(s) are suitable to be parents of an adoptee.

6. The names and addresses of the mother and father are:

She is a minor.  The name and address of the minor mother's parent or guardian who agreed with the placement are

Street  address

City

State

Zip

He is a minor.  The name and address of the minor father's parent or guardian who agreed with the placement are

Street  address

City

State

Zip

City

State

Zip

returned to me.

Mother:

Name

Name(s)

Street address

Father:

Name

Name(s)

Street address

.

.

.

.

City

State

Zip

(PLEASE SEE OTHER SIDE)

Do not write below this line - For court use only

PCA 330   (2/15)   STATEMENT OF PARENT/GUARDIAN TRANSFERRING PHYSICAL CUSTODY OF CHILD FOR ADOPTION

MCL 710.23d

The name and address of each other possible putative father is

6. continued.

Date

Signature of parent/guardian/agency official

Signature of witness

Name of parent/guardian/agency official (print)

Name of witness (print)

Signature of parent/guardian/agency

Signature of witness

Name of parent/guardian/agency official (print)

Name of witness (print)

CERTIFICATION BY PARENT/GUARDIAN OF UNEMANCIPATED MINOR PARENT

I certify that I am the

parent

legal guardian

of

    ,

Name of parent of child

who is an unemancipated minor parent of the child.  I have reviewed this statement and agree with the temporary placement.

Date

Signature of parent/guardian

Name of parent/guardian (print)

Address

City, state, and zip

Signature of witness

Name of witness (print)

REPORT TO COURT FOLLOWING TEMPORARY PLACEMENT

I report that I am assisting in the temporary placement of a child who was placed for purposes of adoption in the home of adoptive
parents as set forth in this statement.  The statement of the prospective adoptive parents evidencing transfer of physical custody of
the child to them is attached.

The parent(s) and prospective adoptive parent(s) have elected not to exchange full identifying information.  The name(s) and
address(es) of the prospective adoptive parent(s) are

Name(s)

Street address

City

State

Zip

Date

Signature of attorney or agency representative

Name of attorney or agency representative (print)

Address

Name of firm or agency

City, state, and zip

.

.