Approved, SCAO JIS CODE: SAC STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION FILE NO. STATEMENT TO ACCOMPANY CONSENT IN DIRECT PLACEMENT DOB: , adoptee COUNTY In the matter of Full name of child 1. I am the parent or guardian of the adoptee and I intend to consent to a direct placement of the adoptee. 2. I have received a list of adoption support groups. 3. I am being assisted by a child-placing agency. I have received a copy of the written document described in MCL 722.956(1)(c). 4. I have received counseling related to this adoption. I waive counseling related to this adoption. 5. I have not received or been promised any money or anything of value for the consent to the adoption, except for lawful payments as itemized on the verified accounting filed with the consent. 6. The validity and finality of my consent is not affected by any collateral or separate agreement between myself and the adoptive parent(s). 7. I understand that the welfare of the adoptee is served if the parent keeps the child-placing agency or Michigan Department of Health and Human Services informed of any health problems that the parent develops that could affect the adoptee. 8. I understand that the welfare of the adoptee is served if I keep my address current with the child-placing agency or Michigan Department of Health and Human Services in order to permit a response to any inquiry concerning medical or social history from an adoptive parent of a minor adoptee or from an adoptee who is 18 years or older. I declare that this statement has been examined by me and that its contents are true to the best of my information, knowledge, and belief. Date Signature of parent or guardian Name of parent or guardian (print) Address City, state, zip Telephone no. CERTIFICATION BY PARENT/GUARDIAN OF UNEMANCIPATED MINOR PARENT I certify that I am the parent legal guardian of Name of parent of child , who is an unemancipated minor parent of the child. I have reviewed this statement and agree with the placement. Date Signature of parent/guardian Name of parent/guardian (print) Address City, state, and zip Signature of witness Name of witness (print) Do not write below this line - For court use only PCA 339 (2/15) STATEMENT TO ACCOMPANY CONSENT IN DIRECT PLACEMENT American LegalNet, Inc. www.FormsWorkFlow.com MCL 710.44(5)