Approved, SCAO FILE NO. STATE OF MICHIGAN 6th JUDICIAL CIRCUIT - FAMILY DIVISION Oakland COUNTY In the matter of adoptee STATEMENT TO ACCOMPANY RELEASE DOB: Full name of child 1. I am the parent or guardian of the adoptee and I intend to sign a release of the child for purposes of adoption. 2. I have received a list of adoption support groups. 3. I intend to release the child to 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 release of the child, except for lawful payments as itemized on the schedule filed with the release. 6. The validity and finality of my release is not affected by any collateral or separate agreement between myself and the adoptive parent, nor between myself and the agency to whom the child is to be released. 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. Signature of parent or guardian Date Name of parent or guardian (print) Address City, state, zip Telephone no. Do not write below this line - For court use only PCA 338 (9/97) STATEMENT TO ACCOMPANY RELEASE American LegalNet, Inc. www.FormsWorkFlow.com MCL 710.29(5); MSA 27.3178(555.29)(5)