In the matter of , adoptee1.I,was adopted by .2.I,, birth parent, had my parental rights terminated by order of this court.3.I desire to rescind the adoption by the stepparent and restore the parental rights of the birth parent.4.A copy of my new live birth certificate is attached.5.The adoptee's name will be .6.The adoptee's legal parents are:7.I REQUEST that the court conduct a hearing, and an investigation if necessary, and enter an order of rescission of the adoptionand restore the parental rights of the petitioner birth parent.I declare that this petition has been examined by me and that its contents are true to the best of my information, knowledge, andbelief.(SEE SECOND PAGE) PCA 349 (2/15) PETITION FOR RESCISSION OF ADOPTION AND ORDER Approved, SCAOFILE NO. MCL 710.66Full name of child at birth Full name of child immediately after adoption Birth date Adoptee's present name Stepparent's name Do not write below this line - For court use only Birth parent's name FirstMiddleLast City, state, zip City, state, zipAddressName of adoptive stepparentTelephone no.Telephone no.AddressName of natural parent Date City, state, zipSignature of adoptee petitionerAddressTelephone no. City, state, zipSignature of birth parent petitionerAddressTelephone no. Date Attorney signature AddressCityStateZip Telephone no.Bar no.Attorney name (type or print)PETITION FOR RESCISSION OFADOPTION AND ORDERSTATE OF MICHIGANJUDICIAL CIRCUIT - FAMILY DIVISIONCOUNTYJIS CODE: PFR American LegalNet, Inc. www.FormsWorkFlow.com DateJudgeBar no. IT IS ORDERED:8.The adoption of the adoptee named above by the stepparent named above is rescinded. The parental rights of thebirth parent named above are restored.9.The petition is denied. American LegalNet, Inc. www.FormsWorkFlow.com