PCA 342 (2/15) PETITION AND ORDER TO APPOINT CONFIDENTIAL INTERMEDIARYIn the matter of , adoptee1.I am anadult adoptee.adoptive parent of the adoptee who is a minor.adult child of the deceased adoptee whose date of death is.I REQUEST that the court appoint a confidential intermediary to search for and contact a former family member of minewho is believed to be mymother.father.grandparent.adult sibling.2.I am a former family member of the adoptee. I am the adoptee'sparent.grandparent.adult sibling.I REQUEST that the court appoint a confidential intermediary to search for and contactthe adult adoptee.an adult child of the deceased adoptee whose date of death is .ORDER3.Date of hearing:Judge:4. is appointed confidential intermediary to search for andcontactthe former mother.the former father.the former grandparent.the adult adoptee.an adult child of the deceased adoptee.adult sibling.The confidential intermediary shall file with the court within 6 months of this order a written report of the intermediary's effortsto search for and contact the individual and any results. The confidential intermediary shall have access to the adoptee's courtfile and records.5.Theformer motherformer fatherhas on file with the central adoption registry a denial of consent to therelease of identifying information. The petition to search for that former parent is denied. Approved, SCAOFILE NO. PETITION AND ORDER TO APPOINTCONFIDENTIAL INTERMEDIARYMCL 710.68b Full name of child PETITION Date Do not write below this line - For court use only Name (type or print) STATE OF MICHIGANJUDICIAL CIRCUIT - FAMILY DIVISIONCOUNTYDateDateDateName of petitioner (type or print)City, state, zipTelephone no.Signature of petitionerAddressBar no.JudgeJIS CODE: ACI American LegalNet, Inc. www.FormsWorkFlow.com