Approved, SCAO JIS CODE: CAG STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION FILE NO. CONSENT TO ADOPTION BY GUARDIAN COUNTY In the matter of Full name of child , adoptee 1. I, Name , am the court-appointed guardian for the child named above. the parent of the child named above. at Date Place The child named above was born 2. I have authority to consent to this adoption by order of the . Court. (A copy of the order is attached and a copy of my current letters of guardianship are attached.) 3. a. A judge or referee of the court, other authorized person, has fully explained to me my legal rights as guardian and the legal rights of the parent(s) of the child named above and that I do not have to sign this consent. I understand that if I do sign this consent, my rights as guardian and the legal rights of each parent will be terminated and the child will be placed with: (See b.i. and b.ii. below.) b. A judge or referee of the court, or other authorized person, has fully explained to me, as guardian of the parent, the legal rights of the parent to the child named above and that I do not have to sign this consent. I understand that if I do sign this consent, I voluntarily and permanently give up, on behalf of the parent, his/her parental rights, and the child will be placed with: (See i and ii below.) i. the petitioner(s), who filed a petition for the adoption of the adoptee and whose name(s) is/are unknown because identifying information is not being exchanged. ii. , who filed a petition for adoption of the adoptee. 4. I have not received or been promised any money or anything of value for the consent to adopt the child named above, except for charges and fees approved by the court. 5. I understand my rights as guardian and the rights of the parent(s) to the child and the right to request a rehearing or to appeal within 21 days after an order is entered terminating the rights of the parent(s) and of myself as guardian. 6. a. As guardian of the child named above, I voluntarily and permanently give up my rights as guardian and the rights of each parent to the child named above and consent to the adoption by the petitioner(s). b. As guardian of the parent and on his/her behalf, I voluntarily and permanently give up his/her parental rights to the child named above and consent to the adoption by the petitioner(s). Date Guardian signature Guardian name (type or print) Address City State Zip See reverse side for certification by judge/referee Do not write below this line - For court use only PCA 308a (2/15) CONSENT TO ADOPTION BY GUARDIAN American LegalNet, Inc. www.FormsWorkFlow.com MCL 700.5215(e), MCL 710.22, MCL 710.43, MCL 710.44, MCL 710.54, MCR 3.801 NOTE: Before taking the consent, the court shall obtain from the parent(s) all the nonidentifying information required by MCL 710.27. CERTIFICATION BY JUDGE/REFEREE An investigation of this consent has been made. At a hearing where a verbatim record of testimony was made, I explained to a. the guardian of the child his/her legal rights and that by signing this consent, the guardian was voluntarily and permanently giving up his/her rights to the child for adoption by the petitioner(s). b. the guardian of the parent the parent's legal rights and that by signing this consent, the guardian was voluntarily and permanently giving up, on behalf of the parent, his/her parental rights to the child for adoption by the petitioner(s). The guardian then voluntarily signed this consent before me. Date Judge/Referee Bar no. NOTE: The following direction is necessary only if the consent is signed before another judge of the family division of the circuit court in Michigan [MCL 710.44(1)]. In other cases see MCL 710.44(2),(4). I direct that the consent of Name of guardian be signed before the judge of County, Michigan or his/her designated referee. Date Judge/Referee Bar no. American LegalNet, Inc. www.FormsWorkFlow.com