Approved, SCAO
JIS CODE: RAG
STATE OF MICHIGAN
JUDICIAL CIRCUIT - FAMILY DIVISION
FILE NO. RELEASE OF CHILD BY CHILD PLACING AGENCY DOB: , adoptee
COUNTY In the matter of
Full name of child
I,
Name of representative
, on behalf of
Name of child placing agency
voluntarily release and relinquish parental rights to the child named above to the Michigan Department of Human Services for the purpose of adoption or suitable placement. I am the duly authorized representative of the child placing agency.
Signature Title
Subscribed and sworn to before me on My commission expires:
Date
Date
in Signature:
Notary public
County, Michigan.
Notary public, State of Michigan, County of
Do not write below this line - For court use only
PCA 306 (11/05)
RELEASE OF CHILD BY CHILD PLACING AGENCY
MCL 710.28, MCL 710.29, MCR 3.801