Approved, SCAO FILE NO. STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION COUNTY In the matter of PETITION AND ORDER TO APPOINT CONFIDENTIAL INTERMEDIARY , adoptee Full name of child PETITION 1. I am an adult adoptee. adoptive parent of the adoptee who is a minor. adult child of the deceased adoptee whose date of death is . Date I REQUEST the court to appoint a confidential intermediary to search for and contact a former family member of mine who is believed to be my mother. father. grandparent. adult sibling. 2. I am a former family member of the adoptee. I am the adoptee's parent. grandparent. adult sibling. I REQUEST the court to appoint a confidential intermediary to search for and contact the adult adoptee. an adult child of the deceased adoptee whose date of death is . Date I declare that this petition has been examined by me and that its contents are true to the best of my information, knowledge, and belief. Date Signature of petitioner Address Name of petitioner (type or print) City, state, zip Telephone no. ORDER 3. Date of hearing: Judge: Bar no. 4. is appointed confidential intermediary to search for and Name (type or print) contact the former mother. the former father. the former grandparent. the adult adoptee. an adult child of the deceased adoptee. adult sibling. The confidential intermediary shall file with the court within 6 months of this order a written report of the intermediary's efforts to search for and contact the individual and any results. The confidential intermediary shall have access to the adoptee's court file and records. 5. The former mother former father has on file with the central adoption registry a denial of consent to the release of identifying information. The petition to search for that former parent is denied. Date Judge Do not write below this line - For court use only MCL 710.68b; MSA 27.3178(555.68b) PCA 342 (9/97) PETITION AND ORDER TO APPOINT CONFIDENTIAL INTERMEDIARY American LegalNet, Inc. www.FormsWorkFlow.com