Approved, SCAO JIS CODE: NPF STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION FILE NO. NOTICE TO PUTATIVE FATHER AND CUSTODY STATEMENT COUNTY In the matter of adult. unemancipated minor. intends to file a petition, has filed a petiton with the court, stating that Name (type or print) TO: Putative father , an 1. a. she is the mother of Name of child (type or print) . . Date an unborn child expected on or about b. you are the father of the child. intends to sign a release or consent relinquishing her rights to the child. has joined with her husband in a petition for adoption. 2. The law provides that as a putative father, you have a right to request custody of the child. The law also provides that your failure to appear at the hearing on the petition shall constitute a denial of your interest in the custody of the child, which shall result in the court's termination of your parental rights to the child. 3. If you do not want to request custody of the child, complete the section below and mail or deliver to Name and address c. she . CUSTODY STATEMENT OF PUTATIVE FATHER 1. I voluntarily state: (check one) I am the father of the child and deny any interest in the custody of the child. I may be the father of the child and deny any interest in the custody of the child. I am not the father of the child. 2. I give up my right to notice of the time and place of hearing to identify the child's father and determine or terminate his rights. I declare that this "Custody Statement of Putative Father" has been examined by me and that its contents are true to the best of my information, knowledge, and belief. Date Signature of witness Name of witness Address City, state, zip Telephone no. Date Signature of putative father Address City, state, zip Telephone no. Signature of parent/guardian/guardian ad litem of minor putative father Do not write below this line - For court use only PCA 316 (2/15) NOTICE TO PUTATIVE FATHER AND CUSTODY STATEMENT American LegalNet, Inc. www.FormsWorkFlow.com MCL 710.36, MCL 710.37, MCR 3.801