en-USIn the matter of en-USFull name of childen-US , adoptee þ en-USUSE NOTE:en-US This release cannot be signed until at least 72 hours after the birth of the adoptee. This form is not for use in cases en-USinvolving an Indian child as defined by MCR 3.002(12). 1. þ I am the þ mother þ father þ of the child named above. My date of birth is en-US en-US . 2. þ The child named above was born on en-USDate of birthen-US at en-USTimeen-US at en-USPlaceen-US . 3. þ I also state: en-US(Write your initials before each item to show you agree with the statement.) þ en-USInitial þ a. þ I have read or had read to me each of my rights as a parent that are described in MCL 710.29(5)(c), and I þ understand these rights. þ en-USInitial þ b. þ This child is not an Indian child according to MCR 3.002(12) and is not eligible for membership in any Indian tribe. þ en-USInitial þ c. þ I am signing this out-of-court release as a free and voluntary act and I have been advised that I cannot be forced þ to sign this out-of-court release for any reason. þ en-USInitial þ d. þ I have not been given or promised any money or other thing of value in exchange for signing this out-of-court þ þ release. þ en-USInitial þ e. þ If I sign this out-of-court release, I understand that I am giving up all my parental rights and authorizing the court þ to permanently terminate all my parental rights, unless the court allows me to revoke my out-of-court release. þ en-USInitial þ f. þ It has been explained to me and I understand all the following: þ i. þ I am not required to sign an out-of-court release. þ ii. þ I may make a temporary placement of my child with the prospective adoptive parent or parents, if I have not þ already done so, or I may continue the temporary placement I have already made, until I choose to sign a þ release in court or sign an out-of-court release. þ iii. þ My obligation to support the child continues until a court of competent jurisdiction modifies or terminates the þ obligation, an order of adoption is entered, or the child is emancipated by operation of law. þ iv. I may request revocation of the out-of-court release I have signed by submitting a timely written request for þ revocation. þ v. þ If I request a revocation of the out-of-court release, I must appear before the court so the court may consider þ whether to grant the revocation. þ en-USInitial þ g. þ I have been advised that I may submit a request for revocation in writing to the adoption attorney or child-placing þ agency that accepted the out-of-court release not more than 5 days, excluding weekends and holidays, after the þ out-of-court release was signed, or I may petition the court on my own for revocation of the out-of-court release þ not more than 5 days, excluding weekends and holidays, after the out-of-court release was signed. þ en-USInitial þ h. þ If I submit a timely request or file a timely petition for revocation, the court may grant the request or deny the þ þ request depending on my fitness and immediate ability to properly care for the child and whether the best interests þ of the child would be served by the revocation. 4. þ I relinquish all my parental rights to my child, including, but not limited to: þ a. þ The right to have or to seek care and custody of the child. þ b. þ The right to have or to seek parenting time with the child. þ c. þ The right to inherit from the child or have the child inherit from me. þ d. þ The right to services and earnings from the child. þ e. þ The right to determine the child222s schooling, religious training, and parenting practices. American LegalNet, Inc. www.FormsWorkFlow.com Out-of-Court Release of Child by Parent þ (4/18) þ Page of File No. 5. þ Of my own free will, I give up completely and permanently my parental rights to my child, and I release my child to þ en-USChild-placing agency or Michigan Department of Health and Human Servicesen-US for the purpose of adoption. 6. þ I acknowledge that I am signing this out-of-court release freely and voluntarily, after my parental rights have been explained þ to me and any questions I may have about it have been fully answered. I understand the rights I am giving up and that an þ þ order terminating my parental rights, when entered by the court, is a permanent termination of all my parental rights. en-USDate þ en-USParent signature þ en-USParent name (type or print) en-USAddress City State Zip þ en-US parent þ The parent signing this release is an unemancipated minor. I am the þ en-US guardian en-US(Copy of letters of authority attached.) þ en-US guardian ad litem en-US(Copy of order attached.) þ of the minor parent, and I join with the minor parent in signing this release. en-USDate þ en-USParent/guardian/guardian ad litem of unemancipated minor signature en-USAddress City State Zipen-USI acknowledge that I have been provided a copy of this form: en-USParent signatureen-USThis out-of-court release was signed in front of me by the parent named above and, if this out-of-court release involves a parenten-USwho is an unemancipated minor, by the parent or guardian of the unemancipated minor: en-USAdoption attorney signature þ en-USAdoption agency representative signature en-USAdoption attorney name (type or print) þ en-USName of adoption agency representative (type or print) þ en-USName of adoption agency (type or print)en-USA request for revocation of this out-of-court release may be submitted to the adoption attorney that witnessed it or to the child-en-USplacing agency that accepted it by mail, fax, or e-mail.en-USAdoption attorney222s contact information: en-USAdoption attorney222s name (type or print) en-USAddress City State Zip en-USAdoption attorney222s e-mail address Adoption attorney222s fax numberen-USChild-placing agency contact information: en-USChild-placing agency222s name and name of caseworker (type or print) en-USAddress City State Zip en-USChild-placing agency222s e-mail address Child-placing agency222s fax numberen-USWITNESS STATEMENT en-USCONTACT INFORMATION FOR REQUESTING REVOCATION OF THIS OUT-OF-COURT RELEASE American LegalNet, Inc. www.FormsWorkFlow.com