Approved, SCAO JIS CODE: NIR STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION COUNTY FILE NO. NOTICE OF INTENT TO RELEASE OR CONSENT NOTE: Personal service of this form is required 30 days before the expected date of confinement. In the matter of Petitioner TO: TAKE NOTICE: The woman named above has filed an ex parte petition with this court which alleges that: 1. She is pregnant out of wedlock and intends to release the expected child for adoption or to consent to the child's adoption. 2. The approximate date of conception was at the following location: 3. Her expected date of confinement is 4. You are the putative father of the expected child. . YOU ARE NOTIFIED AND INFORMED: 5. You have a right to file a notice of intent to claim paternity before the birth of the child with the family division of the circuit court in any county of this state on a form available at this court. 6. If you file a notice of intent to claim paternity, you shall be entitled to notice of any hearing involving that child to determine the identity of the father of the child and any hearing to determine or terminate his paternal rights to this child. 7. YOUR FAILURE TO FILE a notice of intent to claim paternity before the expected date of confinement or before the birth of the child, whichever is later, is a waiver of your right to receive notice of the hearing and is a denial of your interest in custody of the child, which WILL RESULT IN THE COURT'S TERMINATION OF YOUR RIGHTS TO THE CHIILD. Date Deputy clerk PROOF OF PERSONAL SERVICE On at , I personally served a copy of this notice on Time Date at Name . Location I declare that this proof of service has been examined by me and that its contents are true to the best of my information, knowledge, and belief. Date Signature of peace officer/court authorized person Do not write below this line - For court use only PCA 314 (9/07) NOTICE OF INTENT TO RELEASE OR CONSENT MCL 710.34, MCR 3.801, MCR 3.802 American LegalNet, Inc. www.FormsWorkflow.com