Approved, SCAO JIS CODE: CAP FILE NO. STATE OF MICHIGAN CONSENT TO ADOPTION BY PARENT 6th JUDICIAL CIRCUIT - FAMILY DIVISION OAKLAND COUNTY In the matter of , adoptee Full name of child 1. I, mother father , am the (Date of birth (Date of birth ) ) Name of the child named above, who was born at Date 2. . Place A judge or referee of the court, or other authorized person, has fully explained to me my legal rights as a parent and that I do not have to sign this consent to adoption. I understand my parental rights and that if I do sign this consent, except as otherwise stated in item 6, I voluntarily give up permanently all my parental rights to my child for adoptive placement with a. the petitioner(s), who filed a petition for the adoption of the adoptee and whose name(s) is/are unknown because identifying information is not being exchanged. b. , who filed a petition for adoption of my child. Name(s) of petitioner(s) 3. I understand my right to request a rehearing or to appeal within 21 days after an order is entered terminating my parental rights. 4. I have not received or been promised any money or anything of value for the consent to adopt my child except for charges and fees approved by the court. 5. Of my own free will, I give up completely and permanently my parental rights to my child, and I consent to the adoption of my child by the petitioner(s). 6. 7. This consent involves an Indian child as defined in MCR 3.l002(5). The explanation given to me was in a language understood by me or interpreted into my own language if I do not speak English. This consent was given more than 10 days after the birth of the child named above. I understand my consent may be withdrawn for any reason at any time before the entry of a final decree of termination or adoption. I understand that my parental rights may be reinstated without further hearing if the adoption of the child named above is not confirmed. Date Parent signature Address City State Zip parent guardian (copy of letters of authority attached) guardian ad litem (copy of order attached) of the minor parent, and I consent to the minor parent signing this consent to adoption. The parent signing this consent is an unemancipated minor. I am the Date Parent signature Address City State Zip See second page for certification by judge/referee and special acknowledgment for consents by those in the armed services or in prison Do not write below this line - For court use only PCA 308 (3/10) CONSENT TO ADOPTION BY PARENT MCL 710.22, MCL 710.43, MCL 710.44, MCL 710.54, 25 USC 1913(a), MCR 3.801 American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATION BY JUDGE/REFEREE An investigation of this consent has been made. At a hearing where a verbatim record of testimony was made, I explained to the parent her/his legal rights and that by signing this consent, s/he was voluntarily giving up permanently her/his parental rights to the child for adoption by the petitioner(s). The parent then voluntarily signed this consent before me. This consent involves an Indian child. The terms and consequences of the consent were fully explained in detail and were fully understood by the parent or Indian custodian. The parent or Indian custodian fully understood the explanation in English or it was interpreted into a language that the parent or Indian custodian understood. The parent, guardian, or guardian ad litem of the unemancipated minor parent was present during this hearing and voluntarily signed this consent before me. Date Judge/Referee Bar no. NOTE: The following direction is necessary only if the consent is signed before another judge of the family division of the circuit court in Michigan (MCL. 710.44[1]). In other cases, see MCL 710.44(2),(4). I direct that the consent of be signed before the judge of County, Michigan or his/her designated referee. Date Judge/Referee Bar no. In addition to completing the other side of this consent, if the parent signing this consent is in the armed services or is in prison, the following special acknowledgment must be completed by a person authorized by law to administer oaths. SPECIAL ACKNOWLEDGMENT I certify and acknowledge that Is personally known to me, Name of parent Is presently confined stationed at located at Name of place and stated Address City that s/he is the mother State father of the child. I fully explained her/his legal rights as a parent, that s/he did not have to sign this consent to adoption, and that if s/he did sign the consent, s/he would be voluntarily giving up permanently her/his parental rights to the child for purposes of adoption. I also explained her/his right to a rehearing or to appeal within 21 days after an order is entered terminating her/his parental rights. The parent then voluntarily signed this consent. Subscribed and sworn to before me on , Date My commission expires: . County and state Signature: Date Notary public, State of Michigan, County of Notary Public: Name (type or print) Address City, state, zip American LegalNet, Inc. www.FormsWorkFlow.com