Approved, SCAO
JIS CODE: VSL
STATE OF MICHIGAN
JUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY
STATEMENT OF SERVICES PERFORMED BY ATTORNEY 7-DAY 21-DAY
FILE NO.
In the matter of adoptee
Full name of child
DOB: petitioner father. mother of adoptee. father of adoptee.
I am an attorney representing the
petitioner mother.
I state that the following list itemizes the services performed and any fees, compensation, or other thing of value received by or agreed to be paid to me for, or incidental to, the adoption of the child. Date Service Performed Fee, Compensation, or Other Value
SUBTOTAL from 7-Day Statement of Services Performed by Attorney
$0.00 TOTAL I represent a party in this direct placement adoption. I have not requested or received any compensation for the activities described in MCL 710.54(2).
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 Name (print or type)
NOTE: Attach this statement to form PCA 347, "Petitioner's Verified Accounting"
Address City, state, zip Telephone no.
Do not write below this line - For court use only
PCA 346 (9/07)
STATEMENT OF SERVICES PERFORMED BY ATTORNEY
MCL 710.54(7)