Approved, SCAO JUDICIAL CIRCUIT - FAMILY DIVISION Original - Court 1st copy - Secretary Of Interior JIS CODE: PCS, TCS, and MICOURT - CAI STATE OF MICHIGAN FILE NO. COUNTY CERTIFICATE OF ADOPTIVE INFORMATION DOB: , adoptee In the matter of Full name of child 1.Thetribalaffiliationofthechildis 2.Thenamesandaddressesofthebiologicalparentsofthechildare: Nameofbiologicalfather(typeorprint) Address City,state,andzip Nameofbiologicalmother(typeorprint) Address City,state,andzip . 3.Thenamesandaddressesoftheadoptiveparentsofthechildare: Nameofadoptivefather(typeorprint) Address City,state,andzip Nameofadoptivemother(typeorprint) Address City,state,andzip 4.Thenameoftheagencyhavinginformationpertainingtotheadoptionis . Date Signatureofcourtrepresentative Name(typeorprint) Do not write below this line - For court use only PCA 328 (3/16) CERTIFICATE OF ADOPTIVE INFORMATION American LegalNet, Inc. www.FormsWorkFlow.com 23 USC 1951