Approved, SCAO
JIS CODE: ATA
STATE OF MICHIGAN
JUDICIAL CIRCUIT - FAMILY DIVISION
STATEMENT OF PARENT/GUARDIAN AUTHORIZING TEMPORARY PLACEMENT OF COUNTY CHILD FOR ADOPTION
FILE NO.
In the matter of the child
Full name of child
DOB: mother. father. court. (Copy of order is attached.) , a child-placing agency, to make a
1. I have legal and physical custody of the child as guardian pursuant to an order issued by the 2. I authorize
Name of court
temporary placement of the child with prospective adoptive parents in accordance with the Michigan Adoption Code, and a. I have read a preplacement assessment of the prospective adoptive parent(s) that was completed or updated less than a year ago and which states that the prospective adoptive parent(s) are suitable to be parent(s) of an adoptee. OR b. I have been informed that the child-placing agency must give me an opportunity to review the preplacement assessment of the prospective adoptive parent(s) before any temporary placement. 3. I have been informed that I retain full parental rights to the child and that the agency must file a petition on my behalf if I wish to regain custody of my child during the temporary placement in the adoptive home. 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 parent/guardian Name of parent/guardian (print) Signature of parent/guardian Name of parent/guardian (print) Signature of witness Name of witness (print) Signature of witness Name of witness (print)
CERTIFICATION BY PARENT/GUARDIAN OF UNEMANCIPATED MINOR PARENT I certify that I am the parent legal guardian of who is an unemancipated minor parent of the child. I join with the parent in authorizing the child-placing agency to make a temporary placement of the child with the prospective adoptive parents.
Date Signature of parent/guardian Name of parent/guardian (print) Address City Signature of witness Name of witness (print) State Zip
Do not write below this line - For court use only
PCA 329 (9/07)
STATEMENT OF PARENT/GUARDIAN AUTHORIZING TEMPORARY PLACEMENT OF CHILD FOR ADOPTION
MCL 710.23b, MCL 710.23d