Approved, SCAO
JIS CODE: SII
STATE OF MICHIGAN
JUDICIAL CIRCUIT - FAMILY DIVISION
FILE NO. STATEMENT OF IDENTIFYING INFORMATION
COUNTY
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
Address Name
.
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 Address
.
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.
Date Signature of attorney or agency representative Name of attorney or agency representative (print) Name of firm or child-placing agency Address City, state, zip Telephone no. Bar no.
Do not write below this line - For court use only
PCA 340 (9/07)
STATEMENT OF IDENTIFYING INFORMATION
MCL 710.24(5)