Approved, SCAO JIS CODE: ODC STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION COUNTY In the matter of ORDER TO DETERMINE CUSTODY OF CHILD TEMPORARILY PLACED FOR ADOPTION FILE NO. DOB: Full name of child 1. Date of hearing: Judge: Bar no. 2. A petition to determine custody of the child has been filed. 3. Findings of fact and conclusions of law were made on the record. THE COURT FINDS: 4. The child has been temporarily placed for adoption in the home of a prospective adoptive parent and the child remains in this home. has been removed from this home and is in the custody of the child-placing agency. 5. It appears necessary that an investigation should be made to determine if a petition for a child-protective proceeding should be filed in the family division of the circuit court. 6. A petition for the appointment of a guardian has been filed. Pending entry of an order of guardianship, a temporary order of disposition for the welfare of the child should be made. 7. The child should should not be returned to the custody of the parent with authority for legal and physical custody of the child. guardian with authority for legal and physical custody of the child. child-placing agency with legal custody of the child. IT IS ORDERED: 8. The prospective adoptive parent(s), , Name(s) shall within 24 hours of receipt of this order return the child to Name(s) , the parent who has the authority for legal and physical custody of the child. the guardian who has the authority for legal and physical custody of the child. (PLEASE SEE OTHER SIDE) Do not write below this line - For court use only PCA 336 (9/07) ORDER TO DETERMINE CUSTODY OF CHILD TEMPORARILY PLACED FOR ADOPTION MCL 710.23e American LegalNet, Inc. www.FormsWorkflow.com 9. a. is appointed attorney to represent the child in Name all proceedings in this matter until discharged by the court and shall immediately * (See below.) OR b. The matter is referred to the Michigan Department of Human Services to * (See below.) * investigate and, if necessary, file a petition on behalf of the child in the family division of the circuit court under MCL 712A.2(b). If a petition is not filed in the family division within 14 days of this order, the child shall be returned to the parent or the guardian with authority for legal and physical custody. Pending a preliminary hearing in a child-protective proceeding or the return of the child to the parent or guardian, the child shall be moved from the home of the prospective adoptive parent and placed in licensed foster care under the supervision of the Michigan Department of Human Services. 10. Pending hearing on the petition for the appointment of a guardian for the child, the court makes the following disposition for the welfare of the child: Date Judge American LegalNet, Inc. www.FormsWorkflow.com