, adoptee

 .

 .

SE NOTE: This consent cannot be signed until at least 72 hours after the birth of the adoptee. This form is not for use in cases 

involving an Indian child as defined by MCR 3.002(12).

In the matter of 

Full name of child

  U

1. I am the 

 

 mother 

 father 

  of the child named above. My date of birth is 

2. The child named above was born on 

Date of birth

 at 

Time

3. I also state: (Write your initials before each item to show you agree with the statement.)

 

 at 

Place

  a. I have read or had read to me each of my rights as a parent that are described in MCL 710.44(8)(c), and I 

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                understand these rights.

  b. This child is not an Indian child according to MCR 3.002(12) and is not eligible for membership in any Indian tribe.

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  c.  I am signing this out-of-court consent as a free and voluntary act and I have been advised that I cannot be forced

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                to sign this out-of-court consent for any reason.

  d. I have not been given or promised any money or other thing of value in exchange for signing this out-of-court 

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                consent.

  e. If I sign this out-of-court consent, I understand that I am giving up all my parental rights and authorizing the court

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                to permanently terminate all my parental rights, unless the court allows me to revoke my out-of-court consent.

  f.   It has been explained to me and I understand all the following:

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                i.   I am not required to sign an out-of-court consent.
                ii.  I may make a temporary placement of my child with the prospective adoptive parent or parents, if I have not 
                    already done so, or I may continue the temporary placement I have already made, until I choose to sign a
                    consent in court or sign an out-of-court consent.
                iii. My obligation to support the child continues until a court of competent jurisdiction modifies or terminates the 
                    obligation, an order of adoption is entered, or the child is emancipated by operation of law.
                iv. I may request revocation of the out-of-court consent I have signed by submitting a timely written request for
                    revocation.
                v.  If I request a revocation of the out-of-court consent, I must appear before the court so the court may consider
                    whether to grant the revocation.

  g. I have been advised that I may submit a request for revocation in writing to the adoption attorney or child-placing
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                agency that accepted the out-of-court consent not more than 5 days, excluding weekends and holidays, after the
                out-of-court consent was signed, or I may petition the court on my own for revocation of the out-of-court consent
                not more than 5 days, excluding weekends and holidays, after the out-of-court consent was signed.

  h. If I submit a timely request or file a timely petition for revocation, the court may grant the request or deny the  

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                request depending on my fitness and immediate ability to properly care for the child and whether the best interests 
                of the child would be served by the revocation.

 
 

   

   

 

 
 

 
 

 
 
 
 
 
 
 
 
 
 
 

 
 
 
 

 
 
 

4. I relinquish all my parental rights to my child, including, but not limited to:
  a. The right to have or to seek care and custody of the child.
  b. The right to have or to seek parenting time with the child.
  c.  The right to inherit from the child or have the child inherit from me.
  d. The right to services and earnings from the child.
  e. The right to determine the child’s schooling, religious training, and parenting practices.

PCA 355 (5/18) OUT-OF-COURT CONSENT TO DIRECT PLACEMENT ADOPTION BY PARENTMCL 710.44Approved, SCAO                     JIS CODE: OCDSTATE OF MICHIGANJUDICIAL CIRCUIT - FAMILY DIVISIONCOUNTYOUT-OF-COURT CONSENT TO DIRECTPLACEMENT ADOPTION BY PARENTFILE NO.Court addressCourt telephone no.(SEE SECOND PAGE)Out-of-Court Consent to Direct Placement Adoption by Parent 

(5/18)  Page 

  

 of 

  

File No. 

 

 a. The petitioner(s), who have filed or intend to file a petition for the adoption of the adoptee and whose name(s) is/are

        unknown to me because identifying information is not being exchanged.

5. I voluntarily and permanently give up all my parental rights to my child for adoptive placement with
 
 
 
 
 

     
        adoption of my child.

Adoptive parent(s) name(s)

 b. 

 , who filed or intend to file a petition for the

6. I acknowledge that I am signing this out-of-court consent freely and voluntarily, after my parental rights have been explained
 
to me and any questions I may have about it have been fully answered. I understand the rights I am giving up and that an  
  order terminating my parental rights, when entered by the court, is a permanent termination of all my parental rights.

Parent signature

Parent name (type or print)

                     

Date

 

 

Date

 

 

Address                                                                                                                      City                                                          State                         Zip

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

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

  

  

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

Address                                                                                                                      City                                                          State                         Zip

Parent/guardian/guardian ad litem of unemancipated minor signature

I acknowledge that I have been provided a copy of this form: 

Parent signature

WITNESS STATEMENT
This out-of-court consent was signed in front of me by the parent named above and, if this out-of-court consent involves a parent
who is an unemancipated minor, by the parent or guardian of the unemancipated minor:

Adoption attorney signature

Adoption agency representative signature

Adoption attorney name (type or print)

Name of adoption agency representative (type or print)

 

                     

Name of adoption agency (type or print)

 

 

CONTACT INFORMATION FOR REQUESTING REVOCATION OF THIS OUT-OF-COURT CONSENT

A request for revocation of this out-of-court consent may be submitted to the adoption attorney who witnessed it or to the child-
placing agency that accepted it by mail, fax, or e-mail.

Adoption attorney’s contact information: 

Adoption attorney’s name (type or print)

Address                                                                                                                    City                                                           State                        Zip

Adoption attorney’s e-mail address                                                                          Adoption attorney’s fax number

Child-placing agency contact information: 

Child-placing agency’s name and name of caseworker (type or print)

Address                                                                                                                    City                                                           State                        Zip

Child-placing agency’s e-mail address                                                                     Child-placing agency’s fax number