Approved, SCAO JIS CODE: FTP STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION FILE NO. FOLLOW-UP REPORT AFTER TEMPORARY PLACEMENT OF CHILD FOR ADOPTION DOB: , adoptee COUNTY In the matter of Full name of child NOTE: This report is to be completed within 30 days after the transfer of physical custody of the child. This report is in addition to the report included in the statement transferring custody (either form PCA 330 or PCA 331). 1. I am the adoption attorney the child named above. 2. On Date representative of the child-placing agency that assisted in the temporary placement of , for the purpose of adoption, physical custody of the child was transferred to the Name(s) of prospective parent(s) Street address Name(s) of parent(s) City State prospective adoptive parent(s) who reside(s) in Zip County at . 3. The temporary placement was made by Street address . City State Zip 4. Since the transfer of physical custody, the following has occurred a. a petition for adoption was filed by the prospective adoptive parents in b. the child was returned to Name(s) County. , parent(s). guardian(s). child-placing agency. Date Signature of adoption attorney Name (type or print) Firm name Address City, state, zip Telephone no. Bar no. Date Signature of agency representative Name (type or print) Agency name Address City, state, zip Telephone no. Do not write below this line - For court use only PCA 333 (2/15) FOLLOW-UP REPORT AFTER TEMPORARY PLACEMENT OF CHILD FOR ADOPTION MCL 710.23d(3) American LegalNet, Inc. www.FormsWorkFlow.com