Approved, SCAO STATE OF MICHIGAN 6th JUDICIAL CIRCUIT - FAMILY DIVISION Oakland COUNTY In the matter of adoptee FILE NO. STATEMENT TO ACCOMPANY CONSENT IN DIRECT PLACEMENT DOB: Full name of child 1. I am the parent or guardian of the adoptee and I intend to consent to a direct placement of the adoptee. 2. I have received a list of adoption support groups. 3. I am being assisted by a child placing agency. I have received a copy of the written document described in MCL 722.956(1)(c). 4. I have received counseling related to this adoption. I waive counseling related to this adoption. 5. I have not received or been promised any money or anything of value for the consent to the adoption, except for lawful payments as itemized on the schedule filed with the consent. 6. The validity and finality of my consent is not affected by any collateral or separate agreement between myself and the adoptive parent. 7. I understand that the welfare of the adoptee is served if the parent keeps the child placing agency or Michigan Family Independence Agency informed of any health problems that the parent develops that could affect the adoptee. 8. I understand that the welfare of the adoptee is served if I keep my address current with the child placing agency or Michigan Family Independence Agency in order to permit a response to any inquiry concerning medical or social history from an adoptive parent of a minor adoptee or from an adoptee who is 18 years or older. 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 parent or guardian Name of parent or guardian (print) Address City, state, zip Telephone no. Do not write below this line - For court use only PCA 339 (9/97) STATEMENT TO ACCOMPANY CONSENT IN DIRECT PLACEMENT MCL 710.44(5) ; MSA 27.3178(555.44)(5) American LegalNet, Inc. www.FormsWorkFlow.com