Approved, SCAO STATE OF MICHIGAN 6th JUDICIAL CIRCUIT - FAMILY DIVISION Oakland COUNTY In the matter of adoptee FILE NO. PETITIONER'S VERIFIED ACCOUNTING 7 DAY 21 DAY DOB: Full name of child I filed a petition to adopt the adoptee. This accounting, and any previously filed accounting, is a complete itemization of payments/ disbursements of money or anything of value made or agreed to be made by me or on my behalf in connection with this adoption. Except for those payments or disbursements listed in my 7 day accounting, no other payments or disbursements have been made or agreed to be made by me in connection with this adoption. (if this box is checked, write NONE in TOTAL below and date and sign the form. EXPENSES TOTAL 1. Court Filing Fee Petition for Adoption ................................................................................................. Order of Adoption ..................................................................................................... Motion for Early Confirmation ................................................................................... Other petitions, motions, orders ............................................................................... $ $ $ $ $ 0.00 2. Agency/Michigan Family Independence Agency Charges (itemized on other side of this form) ............... $ 3. Attorney Fees (itemized on other side of this form) .................................................................................. $ 4. Traveling Expenses (itemized on other side of this form) ......................................................................... $ 5. Medical, Hospital, Nursing, or Pharmaceutical Expenses (itemized on other side of this form) ................ $ 6. Counseling Services (itemized on other side of this form) ........................................................................ $ 7. Living Expenses (itemized on other side of this form)............................................................................... $ 8. Information Gathering Expenses (itemized on other side of this form) ...................................................... $ 9. Total of Expenses Reported on 7 Day Accounting ................................................................................... $ I REQUEST court approval of these payments and disbursements. $ 0.00 TOTAL I declare that this accounting and the attachments have been examined by me and that the contents are true to the best of my information, knowledge, and belief. Date Signature of petitioner Signature of petitioner Name (print or type) Name (print or type) Address Address City, state, zip Telephone no. City, state, zip Telephone no. NOTE: This petition must be filed at least 7 days before formal placement and 21 days before the final order of adoption. Do not write below this line - For court use only PCA 347 (9/97) PETITIONER'S VERIFIED ACCOUNTING American LegalNet, Inc. www.FormsWorkFlow.com MCL 710.54(7); MSA 27.3178(555.54)(7) ITEMIZED ACCOUNTING OF PAYMENTS/DISBURSEMENTS 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. Write in the date for each payment made, the amount of that payment, who that payment was made to, and the purpose of the payment for the following types. You must attach a receipt for each payment/disbursement. Type 2. Agency Charges - fees and expenses charged by and to be paid to the agency. Type 3. Attorney Fees - fees and expenses charged by and to be paid to the attorney. Type 4. Travel Expense - expenses associated with travel that is necessary to the adoption. Type 5. Medical Expense - expenses connected with birth of the child or illness of the child not covered by birth parent's health care benefits or Medicaid. Type 6. Counseling Expense - expenses for counseling related to the adoption for the parent, guardian, or adoptee. Type 7. Living Expense - expenses of the mother before birth of the child and for no more than six weeks after the birth. Type 8. Information Gathering Expense - expenses for getting required information about the adoptee and the adoptee's biological family. TYPE NO. DATE AMOUNT NAME AND ADDRESS OF RECIPIENT PURPOSE $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ American LegalNet, Inc. www.FormsWorkFlow.com