Approved, SCAO STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION COUNTY In the matter of adoptee PARENT'S OR GUARDIAN'S VERIFIED ACCOUNTING FOR ADOPTION RELEASE OR DIRECT PLACEMENT CONSENT FILE NO. DOB: Full name of child This accounting is a complete itemization of all money or things of value which I have been promised or have received or which have been paid on my behalf in connection with this release or consent. ITEM TOTAL 1. Attorney Fees (itemized on other side of this form) .................................................................................. $ 2. Traveling Expenses (itemized on other side of this form) ......................................................................... $ 3. Medical, Hospital, Nursing, or Pharmaceutical Expenses (itemized on other side of this form) ................ $ 4. Counseling Services (itemized on other side of this form) ........................................................................ $ 5. Living Expenses (itemized on other side of this form)............................................................................... $ 6. Other (itemized on other side of this form) ............................................................................................... $ I REQUEST court approval of these payments and promises. $ TOTAL I declare that this accounting and any attachments have been examined by me and that the contents are true to the best of my information, knowledge, and belief. Date Signature of parent or guardian Name (print or type) Address City, state, zip Telephone no. ORDER The above payments and promises are approved with the following exceptions, if any: Date Judge Bar no. Do not write below this line - For court use only PCA 348 (9/97) PARENT'S OR GUARDIAN'S VERIFIED ACCOUNTING FOR ADOPTION RELEASE OR DIRECT PLACEMENT CONSENT MCL 710.29(5); MSA 27.3178(555.29)(5), MCL 710.44(5); MSA 27.3178(555.44)(5) American LegalNet, Inc. www.FormsWorkFlow.com ITEMIZED ACCOUNTING OF PAYMENTS/PROMISES 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. For each payment or promise made to you or for you, write in the date, the amount, whether the payment was made to you or to someone else, and what the payment or promise was for. Type 1. Type 2. Type 3. Type 4. Type 5. Type 6. TYPE NO. Attorney fees you had in connection with the adoption. Travel expenses you had in connection with the adoption. Medical expenses of the birth mother or child for the pregnancy or birth or any illness of the child which were not covered by your health insurance or medicaid. Counseling expenses for you or the child in connection with the adoption. Living expenses of the birth mother before child's birth and for no more than six weeks after birth. Other: list anything else that you have received, been promised, or which has been paid for you. DATE AMOUNT NAME AND ADDRESS OF RECIPIENT PURPOSE $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ American LegalNet, Inc. www.FormsWorkFlow.com