In the matter of Current full name of child þ DOB: 1. On Date at Location I adopted the child named above. A copy of the adoption order is attached. þ A copy of the child222s birth certificate is attached. 2. The date and place of birth of the child cannot be determined. 3. The recorded date of birth of the child differs from the date of birth determined by a medical assessment of the child. A copy of the assessment is attached. I REQUEST: 4. The court file with the Michigan Department of Health and Human Services the attached delayed registration of foreign birth established by court order and the new name of the child be recorded as New name of child . 5. The court determine the date and place of birth of the child. Date Date Signature of petitioner Signature of petitioner Name of petitioner (type or print) Name of petitioner (type or print) Address Address City, state, zipTelephone no. City, state, zipTelephone no. IT IS ORDERED: 6. The petition is granted and the probate court shall cause the delayed registration of foreign birth established by court order to be filed with the Michigan Department of Health and Human Services. 7. The date of birth of the child is determined to be . 8. The place of birth of the child is determined to be . Date JudgeBar no. PETITION ORDER American LegalNet, Inc. www.FormsWorkFlow.com