Approved, SCAO
Court file only
STATE OF MICHIGAN
JUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY
Court address
STATEMENT OF PREFERENCE
CASE NO. PETITION NO.
Court telephone no.
1. In the matter of
(name(s), alias(es), DOB)
2. The above named American Indian child has been placed with: a. a member of his or her extended family.
Full name (type or print) City, county, and state
b. a foster home licensed, approved, or specified by the child's tribe.
Full name (type or print) City, county, and state
c. other Indian foster family licensed or approved by a non-Indian licensing authority.
Full name (type or print) City, county, and state
d. An institution for children approved by an Indian tribe or operated by an Indian organization that has a program suitable to meet the child's needs:
Full name (type or print) City, county, and state
e. other non-Indian family.
Full name (type or print) City, county, and state
3. The good cause for not placing the child with a family having preference under the Indian Child Welfare Act of 1978 is:
Date
Signature Placing agency
Do not write below this line - For court use only
JC 51 (6/03)
STATEMENT OF PREFERENCE
25 USC 1915, MCR 3.980(C)(5)