Approved, SCAO
JIS CODE: RQC
STATE OF MICHIGAN
JUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY
Court address
REQUEST FOR CONFIDENTIALITY
CASE NO. PETITION NO.
Court telephone no.
1. In the matter of
name(s), alias(es), DOB
2. The minor is an American Indian child and either is eligible to be placed for adoption or presently is in an adoptive placement. 3. I,
Name
, am the child's natural father and ask that my identity be kept
confidential. 4. I,
Name
, am the child's natural mother and ask that my identity be kept
confidential.
Signature
Subscribed and sworn to before me on My commission expires:
Date
Date
, Signature:
Deputy clerk/Notary public
County, Michigan.
Notary public, State of Michigan, County of
Use note to court: This Request must be sent to the Secretary of the Interior with the final order of adoption if the minor is adopted.
Do not write below this line - For court use only
JC 50 (11/05)
REQUEST FOR CONFIDENTIALITY
25 USC 1951(c)