Statement Of Identifying Information
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Statement Of Identifying Information Form. This is a Michigan form and can be use in Oakland Local County.
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Tags: Statement Of Identifying Information, PCA-340, Michigan Local County, Oakland
Approved, SCAO
JIS CODE: SII
FILE NO.
STATE OF MICHIGAN
STATEMENT OF
IDENTIFYING INFORMATION
JUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY
In the matter of adoptee
DOB:
Full name of child
1. I am assisting the
parent
guardian
in this adoption.
2. The parties have elected not to exchange identifying information.
3. The surname and current place of residence of the adoptee are
Name
.
Address
4. The name and address of each parent are:
Name and address of mother
Name and address of father
5. The name and address of the court-appointed guardian of the adoptee are
Name
.
Address
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 attorney or agency representative
Name of attorney or agency representative (print)
Bar no.
Name of firm or child-placing agency
Address
City, state, zip
Telephone no.
Do not write below this line - For court use only
PCA 340 (9/11)
STATEMENT OF IDENTIFYING INFORMATION
MCL 710.24(5)
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