Approved, SCAO JIS CODE: PHT STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION COUNTY PETITION FOR HEARING TO IDENTIFY FATHER AND DETERMINE OR TERMINATE HIS RIGHTS FILE NO. In the matter of Full name of child , adoptee 1. I am the mother of the adoptee named above who was born out of wedlock on Date at . The adoptee resides at City, county, and state . Address City State Zip 2. An action within the jurisdiction of the family division of circuit court involving the family or family members of the minor has been previously filed in assigned to Judge 3. I plan to sign a release consent Court, Case Number , and remains is no longer , was pending. giving up my parental rights to the child. 4. I have joined with my husband in a petition for adoption. 5. The child is an Indian child as defined in MCR 3.002(12). The identity of the tribe is 6. The putative father of my child is: Name (type or print) Birthdate (if unknown, state if over 18 years old) Address City, state, zip Name of tribe, if known . . 7. For part or all of the time from conception to the date the child was born, I was married to whose last-known address is Name (type or print) . He is not the father of the child. (SEE SECOND PAGE) Do not write below this line - For court use only American LegalNet, Inc. www.FormsWorkFlow.com MCL 710.22(d), MCL 710.36, 25 USC 1901 et seq., MCL 712B.1 et seq., MCR 3.801, MCR 3.803 PCA 310 (2/15) PETITION FOR HEARING TO IDENTIFY FATHER AND DETERMINE OR TERMINATE HIS RIGHTS 8. I request that the court hold a hearing to determine the identity of the father of my child and to determine or terminate his parental rights. Date Attorney signature Attorney name (type or print) Address City, state, zip Telephone no. Bar no. Signature of petitioner Name (type or print) Address City, state, zip Telephone no. Agency Contact Information: Name of agency representative (type or print) Agency name Telephone no. E-mail Address City, state, zip CERTIFICATION BY PARENT/GUARDIAN OF UNEMANCIPATED MINOR PARENT I certify that I am the parent legal guardian of Name of parent of child , who is an unemancipated minor parent of the child. I have reviewed this petition and agree with it. Date Signature of parent/guardian Name of parent/guardian (print) Address City, state, and zip Signature of witness Name of witness (print) American LegalNet, Inc. www.FormsWorkFlow.com