Approved, SCAO JIS CODE: ACF STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION FILE NO. PETITION AND ORDER FOR APPROVAL OF CONFIDENTIAL INTERMEDIARY FEE COUNTY In the matter of Full name of child , adoptee PETITION 1. I was appointed by the court to serve as a confidential intermediary to search for and to contact a former family member of the adoptee. the adoptee. an adult child of the adoptee. 2. Services have been rendered and expenses incurred while acting as the court-appointed confidential intermediary. 3. Except for actual expenses incurred in performing services, I have not requested nor accepted any money or thing of value for serving as the confidential intermediary. 4. The expenses incurred, the nature of services rendered, and the fee for services are: (attach additional sheets if needed) 5. I REQUEST that the court allow the fee. Date Signature of petitioner Name of petitioner (type or print) Address City, state, zip Telephone no. CONSENT / OBJECTION 6. The court appointed the petitioner as my confidential intermediary. I have received and reviewed the above petition for approval of the fee. I consent to the fee and waive the hearing on this petition. I object to the fee and request a hearing on this petition. Date Signature Name (type or print) ORDER 7. Date of hearing: Judge: Bar no. 8. Notice of hearing has been given to or waived by the interested parties. 9. The fee requested in the petition is reasonable and is approved except: Date Judge Do not write below this line - For court use only American LegalNet, Inc. www.FormsWorkFlow.com PCA 343 (2/15) PETITION AND ORDER FOR APPROVAL OF CONFIDENTIAL INTERMEDIARY FEE MCL 710.68b