In the matter of Full name of child , adoptee þ The petitioners are: NameRelationshipto AdopteeAddress, City, State, ZipDate and Placeof Birth Adopting parentMaiden: Adopting parentMaiden:Each adopting petitioner states: þ 1. þ An action within the jurisdiction of the family division of circuit court involving the family or family members of the minor þ has been previously filed in Court, Case Number , was þ assigned to Judge , and þ remains þ is no longer þ pending. 2. þ The adoptee was born on Birth date and time at City, county, and state of birth . þ parent/guardian. þ 3. þ The adoptee was temporarily placed in my home on Date by a þ child-placing agency. 4. þ The adoptee will be my heir at law. þ not be changed. 5. þ The adoptee222s name will þ be changed to First Middle Last . 6. þ The adoptee222s property is . þ 7. þ The parties have elected not to exchange identifying information. Verified statement of identifying information (form PCA 340) attached.Note: Do not complete items 8 and 9 if item 7 is checked. 8. þ The adoptee is Full name of child (type or print) þ þ Present residential address (if known) The adoptee222s parents are: þ Father222s name (type or print) Birth date þ Mother222s name and maiden name (type or print) Birth date þ Address þ Address þ City, state, zip þ City, state, zip þ 9. þ The adoptee222s court-appointed guardian and/or conservator is/are Name(s) and address(es) þ þ . American LegalNet, Inc. www.FormsWorkFlow.com Petition for Direct Placement Adoption (6/17)Page of File No. 10.I have received a copy of the reasonably obtainable nonidentifying information required for a placement of the child for adoption. A copy is attached. have have not11.I have been informed of the availability of counseling services. Ireceived counseling. 12.No preplacement assessments have been completed on us other than those attached. Preplacement assessments have been started but not completed as follows: (Attach separate sheet as needed.)13.I am married but my spouse is not joining me in this petition because 14.The adoptee is an Indian child as defined in MCR 3.002(12). The identity of the tribe is Name of tribe, if known . The appropriate consents have been executed pursuant to MCL 712B.13 and the Michigan Adoption Code.I REQUEST: 15.Termination of all existing parental rights inconsistent with the order of adoption, entry of an order approving placement of the child with me, and entry of an order of adoption with the adoptee222s name recorded as stated in item 5. 16.The adoption be completed immediately because 17.The court to waive the required investigation because the adoptee has been placed in foster care with me for at least 12 months and a foster family study was completed or updated within the last 12 months.I declare that the statements above are true to the best of my information, knowledge, and belief. Attorney signature Date Attorney name (type or print) Bar no. Signature of petitioner Address Signature of petitioner City, state, zipTelephone no. Petitioner telephone no.Agency Contact Information: Name of agency representative (type or print) Address Agency name City, state, zip Telephone no. E-mail American LegalNet, Inc. www.FormsWorkFlow.com Petition for Direct Placement Adoption þ (6/17) þ Page of File No. IT IS ORDERED: þ 18. þ The preplacement assessment filed with the petition has been reviewed by the court and þ þ a. it is a sufficient investigation of the adoptive home, and no further investigation is required. þ þ b. þ Court agent or employee, child-placing agency þ is directed to conduct an additional investigation and report its findings in writing to this court, within 3 months of þ this order, in accordance with the provisions of section 46 of the Michigan Adoption Code. þ 19. þ The full investigation is waived. The petitioner(s) shall file a copy of the most recent foster family study as updated and þ supplemented. þ 20. þ The petitioner(s) shall give notice of this petition to the persons prescribed in MCR 3.800(B) in accordance with MCR þ 3.802(A)(3) (use form PCA 352). Date þ Judge Bar no. American LegalNet, Inc. www.FormsWorkFlow.com