Approved, SCAO STATE OF MICHIGAN 6th JUDICIAL CIRCUIT - FAMILY DIVISION Oakland COUNTY In the matter of the child STATEMENT OF PROSPECTIVE ADOPTIVE PARENT TRANSFERRING PHYSICAL CUSTODY OF CHILD FOR ADOPTION FILE NO. DOB: Full name of child 1. Physical custody of the child was transferred to me on . Date 2. I am a prospective adoptive parent and a resident of Michigan. I will reside with the child in Michigan until a change of residence is approved by the court after formal placement occurs. 3. The temporary placement will not become formal until both parents consent to adoption or release their parental rights and the court orders the termination of parental rights of both parents and approves the placement. 4. I understand if the court enters an order directing return of the child to the parent or guardian with legal custody, I must return physical custody of the child to the parent or guardian named in the order within 24 hours of being served with the court order. I declare under penalty of perjury 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 prospective adoptive parent Signature of witness Name of prospective adoptive parent (print) Name of witness (print) Signature of prospective adoptive parent Name of prospective adoptive parent (print) Address City, state, and zip Do not write below this line - For court use only PCA 332 (9/97) STATEMENT OF PROSPECTIVE ADOPTIVE PARENT TRANSFERRING PHYSICAL CUSTODY OF CHILD FOR ADOPTION MCL 710.23d; MSA 27.3178(555.23d) American LegalNet, Inc. www.FormsWorkFlow.com