Approved, SCAO JIS CODE: PCS and MiCOURT - PVA TCS - PVA7 STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION FILE NO. PETITIONER'S VERIFIED ACCOUNTING COUNTY In the matter of Full name of child DOB: , adoptee I filed a petition to adopt the adoptee. This accounting is a complete itemization of payments/disbursements of money or anything of value made or agreed to be made by me or on my behalf in connection with this adoption as of this date. Form PCA 347a will be submitted to report any additional payments/disbursements of money or anything of value made or agreed to be made by me or on my behalf in connection with this adoption. EXPENSES 1. Court Filing Fee Petition for Adoption ................................................................................................. Order of Adoption ..................................................................................................... Motion for Early Confirmation .................................................................................... Birth Certificate Fee .................................................................................................. Other petitions, motions, orders ................................................................................ TOTAL $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 2. Agency/Michigan Department of Health and Human Services Charges (itemized on other side of this form) 3. Attorney Fees (itemized on other side of this form) .................................................................................. 4. Travel Expenses (itemized on other side of this form) .............................................................................. 5. Medical, Hospital, Nursing, or Pharmaceutical Expenses (itemized on other side of this form) ................ 6. Counseling Services (itemized on other side of this form) ........................................................................ 7. Living Expenses (itemized on other side of this form) .............................................................................. 8. Information Gathering Expenses (itemized on other side of this form) ..................................................... 9. Other (itemized on other side of this form) ................................................................................................. I REQUEST that the court approve these payments and disbursements. TOTAL I declare that this accounting and the attachments have been examined by me and that the contents are true to the best of my information, knowledge, and belief. Date Signature of petitioner Name (print or type) Address City, state, zip Telephone no. Signature of petitioner Name (print or type) Address City, state, zip Telephone no. NOTE: This accounting must be filed at least 7 days before formal placement for adoption. Do not write below this line - For court use only PCA 347 (3/16) PETITIONER'S VERIFIED ACCOUNTING American LegalNet, Inc. www.FormsWorkFlow.com MCL 710.54(7), MCR 3.803(A) ITEMIZED ACCOUNTING OF PAYMENTS/DISBURSEMENTS Instructions: The following are types of expenses that must be itemized. Each type of expense is explained. For each type, identify the type by number, list each expense in that type separately, total the amounts, and place the total under the same type number on the front of this form. If the space provided below is not adequate, make copies before writing any information on this form. Write in the date for each payment made, the amount of that payment, who that payment was made to, and the purpose of the payment for the following types. You must attach a receipt for each payment/disbursement. Type 2. Agency Charges - fees and expenses charged by and to be paid to the agency. Type 3. Attorney Fees - fees and expenses charged by and to be paid to the attorney. Type 4. Travel Expenses - expenses associated with travel that are necessary to the adoption. Type 5. Medical Expenses - expenses connected with the birth of the child or illness of the child not covered by the birth parent's health care benefits or Medicaid. Type 6. Counseling Expenses - expenses for counseling related to the adoption for the parent, guardian, or adoptee. Type 7. Living Expenses - expenses of the mother before the birth of the child and for no more than six weeks after the birth. Type 8. Information Gathering Expenses - expenses for getting required information about the adoptee and the adoptee's biological family. Type 9. Other - includes copy costs, process server fees, etc. TYPE NO. DATE AMOUNT NAME AND ADDRESS OF RECIPIENT PURPOSE $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ American LegalNet, Inc. www.FormsWorkFlow.com