Approved, SCAO FILE NO. STATE OF MICHIGAN 6th JUDICIAL CIRCUIT - FAMILY DIVISION Oakland COUNTY In the matter of FOLLOWUP REPORT AFTER TEMPORARY PLACEMENT OF CHILD FOR ADOPTION DOB: Full name of child NOTE: This report is to be completed within 30 days after the transfer of physical custody of the child. This report is in addition to the report included in the statement transferring custody (either Form PCA 330 or PCA 331). 1. I am the adoption attorney the above named child. representative of the child placing agency that assisted in the temporary placement of 2. On , for the purpose of adoption, physical custody of the child was transferred to the Date prospective adoptive parent(s) who reside Name(s) of prospective parent(s) in this county at . Street address City Zip 3. The temporary placement was made by Name(s) of parent(s) . Street address City State Zip 4. Since the transfer of physical custody, the following has occurred: a. a petition for adoption was filed by the prospective adoptive parents in this county on . b. no petition for adoption was filed and physical custody of the child was returned on to Date , parent(s). guardian(s). child placing agency. Name(s) c. neither of the above. I declare that this report has been examined by me and that its contents are true to the best of my information, knowledge, and belief. Date Date Signature of adoption attorney Signature of agency representative Name (type or print) Bar no. Name (type or print) Firm name Agency name Address Address City, state, zip Telephone no. City, state, zip Telephone no. Do not write below this line - For court use only MCL 710.23d(3); MSA 27.3178(555.23d)(3) PCA 333 (9/97) FOLLOWUP REPORT AFTER TEMPORARY PLACEMENT OF CHILD FOR ADOPTION American LegalNet, Inc. www.FormsWorkFlow.com