In the matter of adoptee 

Full name of child

  DOB: 
 

1. I am assisting the 

 parent 

 guardian 

in this adoption.

2. The parties have elected not to exchange identifying information.

3. The surname and current place of residence of the adoptee are 

Name

Address

4. The name and address of each parent are:

Name and address of mother

Name and address of father

 5. The name and address of the court-appointed guardian of the adoptee are 

Name

 

 .

 .

I declare that this statement has been examined by me and that its contents are true to the best of my information, knowledge,
and belief.

Signature of attorney or agency representative

Name of attorney or agency representative (print)                           Bar no.

Name of firm or child-placing agency

City, state, zip                                                                        Telephone no.

 

                     

  

    .

 

 

 

 

Address

Date

Address

Approved, SCAOJIS CODE:SIIDo not write below this line - For court use onlySTATE OF MICHIGANJUDICIAL CIRCUIT - FAMILY DIVISIONCOUNTY STATEMENT OFIDENTIFYING INFORMATIONFILE NO.PCA 340 (6/17) STATEMENT OF IDENTIFYING INFORMATIONMCL 710.24(7)

PCA 340, Statement of Identifying Information

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the Michigan state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

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About This Form:

• Sourced from www.courts.michigan.gov/adoptions-court-forms (2023-03)
• Page(s): 1
• Fields(s): 21
• Average fields per page: 21
• Reading Level: Grade 8
• LIST Grouping(s): Unknown

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