Approved, SCAO JIS CODE: PRC STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION COUNTY PETITION BY PARENT/GUARDIAN FOR RETURN OF CHILD AND EX PARTE ORDER FILE NO. In the matter of 1.I am the Full name of child DOB: with the right to legal and physical custody of the child. a child-placing agency in temporarily placing the child in the home of parent legal guardian 2. I was assisted by an adoption attorney prospective adoptive parents. 3. The persons interested in this proceeding are: NAME RELATIONSHIP ADDRESS Father of Child Mother of Child Guardian of Child Prospective Parent(s) Adoption Attorney Child-Placing Agency 4. I REQUEST that the temporary placement be revoked and that the court issue an ex parte order directing the prospective adoptive parents to immediately return the child to me. Date Signature of parent Name (type or print) Signature of parent Name (type or print) CONSENT TO RETURN OF CHILD I am a prospective adoptive parent and I presently have physical custody of the child. The parent or guardian of the child has requested that physical custody of the child be returned to him/her and that the temporary placement of the child with me be revoked. I consent to the return of the child to the parent or guardian. Date Signature of prospective adoptive parent Name (type or print) Signature of prospective adoptive parent Name (type or print) (SEE SECOND PAGE) Do not write below this line - For court use only MCL 710.23d, MCL 710.23e PCA 337 (2/15) PETITION BY PARENT/GUARDIAN FOR RETURN OF CHILD AND EX PARTE ORDER American LegalNet, Inc. www.FormsWorkFlow.com EX PARTE ORDER Date of Entry: Judge: Bar no. IT IS ORDERED that the prospective adoptive parent(s), Name(s) , Name shall return the child within 24 hours of receipt of this order to the parent/guardian with authority for legal and physical custody of the child. Judge American LegalNet, Inc. www.FormsWorkFlow.com