Approved, SCAO

STATE OF MICHIGAN

JUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY

PETITION AND ORDER TO APPOINT
CONFIDENTIAL INTERMEDIARY

JIS CODE:  ACI

FILE NO.

In the matter of

Full name of child

   , adoptee

PETITION

1. I am an

adult adoptee.
adult child of the deceased adoptee whose date of death is

adoptive parent of the adoptee who is a minor.

.

Date

I REQUEST that the court appoint a confidential intermediary to search for and contact a former family member of mine
who is believed to be my

mother.

father.

grandparent.

adult sibling.

2. I am a former family member of the adoptee.  I am the adoptee's

parent.

grandparent.

adult sibling.

I REQUEST that the court appoint a confidential intermediary to search for and contact

the adult adoptee.

an adult child of the deceased adoptee whose date of death is

 .

Date

Date

/s/
Signature of petitioner

Name of petitioner (type or print)

3. Date of hearing:

4.

Name (type or print)

Address

City, state, zip

ORDER

Judge:

Telephone no.

    is appointed confidential intermediary to search for and

Bar no.

contact

the former mother.
the adult adoptee.

the former father.
an adult child of the deceased adoptee.

the former grandparent.
adult sibling.

The confidential intermediary shall file with the court within 6 months of this order a written report of the intermediary's efforts
to search for and contact the individual and any results.  The confidential intermediary shall have access to the adoptee's court
file and records.

5. The

former mother

former father

has on file with the central adoption registry a denial of consent to the

release of identifying information.  The petition to search for that former parent is denied.

Date

Judge

Do not write below this line - For court use only

PCA 342   (2/15)   PETITION AND ORDER TO APPOINT CONFIDENTIAL INTERMEDIARY

MCL 710.68b