RELEASE OF CHILD BY GUARDIAN

JIS CODE:  RCG

FILE NO.

Approved, SCAO

STATE OF MICHIGAN

JUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY

In the matter of

Full name of child

1. I,

Name

the child named above.

, am the court-appointed guardian for

the parent of the child named above.

The child named above was born

Date

     at

Place

 .

2. I have authority to sign this release of the child named above for adoption by order of the
    Court (a copy of the order is attached and a copy of my current letters of guardianship are attached).

3.

a. A judge or referee of the court, or other authorized person, has fully explained to me my legal rights as guardian and the legal
rights of the parent(s) of the child named above and that I do not have to sign this release.  I understand that if I do sign this
release, my rights as guardian and the legal rights of each parent will be terminated.

b. A judge or referee of the court, or other authorized person, has fully explained to me, as guardian of the parent, the legal rights
of the parent to the child named above and that I do not have to sign this release.  I understand that if I do sign this release,
I voluntarily and permanently give up, on behalf of the parent, his/her parental rights to the child.

4. I have not received or been promised any money or anything of value for the release of the child, except for charges and fees

approved by the court.

5. I understand my rights as guardian and the rights of the parent(s) to the child and the right to request a rehearing or to appeal

within 21 days after an order is entered terminating the rights of the parent(s) and of myself as guardian.

6.

a. As guardian of the child named above, I voluntarily and permanently give up my rights as guardian and the rights of each

parent to the child named above.

b. As guardian of the parent and on his/her behalf, I voluntarily and permanently give up his/her parental rights to the child named

Child-placing agency or Michigan Department of Health and Human Services

above.

I release the child to

for the purpose of adoption.

Date

Address

Guardian signature

Guardian name (type or print)

City

 State

       Zip

See reverse side for certification by judge/referee

Do not write below this line - For court use only

PCA 305a   (2/15)   RELEASE OF CHILD BY GUARDIAN

MCL 700.431(1)(c), MCL 710.28, MCL 710.29,
MCL 710.54, MCR 3.801

NOTE:  Before taking the release, the court shall
obtain  from  the  parent(s)  all  the  nonidentifying
information required by MCL 710.27.

CERTIFICATION BY JUDGE/REFEREE

An investigation of this release has been made. At a hearing where a verbatim record of testimony was made, I explained to

a. the guardian of the child his/her legal rights and that by signing this release, the guardian was voluntarily and permanently

giving up his/her rights to the child.

b. the guardian of the parent the parent's legal rights and that by signing this release, the guardian was voluntarily and

permanently giving up, on behalf of the parent, his/her parental rights to the child.

The guardian then voluntarily signed this release before me.

The child named above is over five years of age, and the court finds that the child is best served by this release.

Date

Judge/Referee

Bar no.