In the matter of 

Full name of child

 

 

 

 

 

 
 
1. I, 

Name

 , 

Name of tribe and identification no. (if one)

 

 , am the 

  mother 
  father 

(Date of birth 

(Date of birth 

 

 

  of the child named above, who was born 

Date

 at 

Place

. A judge has fully explained to me my legal rights as a parent and that I do not have to sign this release of my parental rights. 

  The explanation given to me was in a language understood by me or interpreted into my own language if I do not speak  
  English. I understand my parental rights and that if I do sign this release, I voluntarily and permanently give up all of my 
  parental rights to my child.

3. This release constitutes a consent for adoption under MCL 712B.13 and is not given before or within 10 days after the birth 
  of my child. I understand that my consent and release may be withdrawn for any reason at any time before the entry of a final 
  order of adoption by filing a written demand requesting the return of my child.

4. I understand my right to request a rehearing or to appeal within 21 days after an order is entered terminating my parental rights.

5. I have not received or been promised any money or anything of value for the release of my child except for charges and fees
  approved by the court.

6. Of my own free will, I give up completely and permanently my parental rights to my child. I release my child, for the purpose 

 )
 )

 . 

 .

of adoption, to 

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

 

 

 

 

 

 

 
 
 The parent signing this release is an unemancipated minor.  I am the   
 
 

 
  of the minor parent, and I join with the minor parent in signing this release.

  

  

 

 

 

 

 

  parent
  guardian (Copy of letters of authority attached.)
  guardian ad litem (Copy of order attached.)

City 

 

State 

 

Zip

Parent signature

Parent name (type or print)

 

 

 

 

Parent/guardian of unemancipated minor signature

Address   

 

 

 

City 

 

State 

 

Zip

See reverse side for certification by judge and statement of interpreter.

 

 

 

 

 

 

 

Address   
 

 

 

 

 

 

  2

   

Date

Date

Approved, SCAOPCS CODE: RIPTCS CODE: RICPDo not write below this line - For court use onlySTATE OF MICHIGANJUDICIAL CIRCUIT - FAMILY DIVISIONCOUNTYRELEASE OF INDIAN CHILD BY PARENTFILE NO.PCA 305-I (9/17) RELEASE OF INDIAN CHILD BY PARENTMCL 710.28, MCL 710.29, MCL 710.54, MCL 712B.13, MCL 712B.27, 25 USC 1913(a), MCR 3.801. At a hearing where a verbatim record of testimony was made, I explained to the parent her/his legal rights and that, by signing 
this release, s/he was voluntarily and permanently giving up her/his parental rights to the Indian child. The parent then voluntarily 

 
  signed this release before me.

  2

1. Notice of this proceeding was given as required by MCR 3.802(A)(3), and an investigation of this release has been made.  

 3. The parent, guardian, or guardian ad litem of the unemancipated minor parent was present during this hearing and voluntarily
  signed this release before me.

 

 4. The Indian child named above is over 5 years of age, and the court finds that the child is best served by this release.

Date

 

Judge  

 

 

Bar no.

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

STATEMENT OF INTERPRETER

I state that this proceeding was interpreted by me to the parent in his/her spoken language of 

Spoken language of parent

 

 

 

 

 

 

 

Subscribed and sworn to before me on 

My commission expires: 

Date

  Signature: 

 

Notary public, State of Michigan, County of 

Date

 

Interpreter signature

 , 

County and state

 , 

Name (type or print)

 .

 . 

Address   

 

 

 

City 

 

 

 

State 

 

Zip

Release of Indian Child by Parent 

(9/17)  Page 

  

 of 

  

File No.