Approved, SCAO JIS CODE: CTC STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION COUNTY STATEMENT OF CHILD-PLACING AGENCY TRANSFERRING PHYSICAL CUSTODY OF CHILD FOR ADOPTION FILE NO. In the matter of Full name of child DOB: 1. I am a representative of the child-placing agency and make this statement on behalf of the agency. 2. The agency is making a temporary placement of the child in a prospective adoptive home as authorized by the parent(s) or guardian(s) of the child. (copy of authorization attached) 3. On Date , for the purpose of adoption, physical custody of the child was transferred to the Name(s) of parent(s) Street address City prospective adoptive parent(s) who reside(s) in Zip County at . 4. The parent(s) or guardian(s) having legal custody of the child retain full parental rights to the child. This temporary placement may be revoked by the agency filing a petition in this court on behalf of the parent(s) or guardian(s) requesting that the child be returned to the parent(s) or guardian(s). 5. The agency has read the preplacement assessment of the prospective adoptive parent(s) that was completed or updated less than a year ago and that states that the prospective adoptive parent(s) are suitable to be adoptive parent(s). The child-placing agency has given the parent or guardian who authorized temporary placement an opportunity to review the preplacement assessment. 6. The names and addresses of the mother and father are: Mother: Name Street address City State Zip She is a minor. The name and address of the minor mother's parent or guardian who agreed with the placement are Name(s) Street address City Street address State City Zip State Zip . Father: He is a Name legal putative father of the child. He is a minor. The name and address of the minor father's parent or guardian who agreed with the placement are Name(s) Street address City State Zip . (SEE SECOND PAGE) Do not write below this line - For court use only PCA 331 (2/15) STATEMENT OF CHILD-PLACING AGENCY TRANSFERRING PHYSICAL CUSTODY OF CHILD FOR MCL 710.23d ADOPTION American LegalNet, Inc. www.FormsWorkFlow.com 6. continued The name and address of each other possible putative father is . Date Signature of agency representative Name of agency representative (print) Signature of witness Name of witness (print) REPORT TO COURT FOLLOWING TEMPORARY PLACEMENT I report that I am a representative of the agency authorized to make this report. The agency has been authorized by the parent or guardian to make the temporary placement of the child in the home of the prospective adoptive parent(s) set forth in the above statement. The statement of prospective adoptive parent(s) evidencing transfer of physical custody of the child to them and the authorization (form PCA 329) is attached. I declare that the statement in this report has been examined by me and that its contents are true to the best of my information, knowledge, and belief. Date Name of agency representative (print) Name of agency Signature of agency representative Address City, state, and zip American LegalNet, Inc. www.FormsWorkFlow.com