Approved, SCAO JIS CODE: CAD STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION FILE NO. CONSENT TO ADOPTION BY AGENCY/COURT COUNTY In the matter of 1. I, *Name Full name of child DOB: , on behalf of *Name of agency or court , adoptee voluntarily consent to the adoption of the child named above by as requested in a petition on file or to be filed in court. 2. I am a representative authorized to execute this consent. Date Signature Title Subscribed and sworn to before me on My commission expires: Date Date , in Signature: Notary public County, Michigan. *The consenting party in item 1 must be one of the following: 1. A representative authorized to consent on behalf of the Michigan Department of Health and Human Services or of a child-placing agency to whom the child has been permanently committed by an order of the family division of the circuit court. 2. The family division of the circuit court having permanent custody of the child. (Notarization not required.) 3. A representative authorized to consent on behalf of the Michigan Department of Health and Human Services or of a child-placing agency to whom the child has been released. 4. A representative authorized to consent on behalf of a child-placing agency of another state or country, which has authority to consent to the adoption. 5. An individual or official authorized by tribal law or order of the tribal court to give consent. Do not write below this line - For court use only PCA 309 (2/15) CONSENT TO ADOPTION BY AGENCY/COURT American LegalNet, Inc. www.FormsWorkFlow.com MCL 710.43, MCL 710.44, MCR 3.801