Approved, SCAO JIS CODE: PDC STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION COUNTY PETITION TO DETERMINE CUSTODY OF CHILD TEMPORARILY PLACED FOR ADOPTION FILE NO. In the matter of Full name of child DOB: 1.On Date the child was temporarily placed in the home of the prospective adoptive parent(s). 2. Physical custody of the child was transferred to the prospective adoptive parents by a. the parent/guardian with legal and physical custody of the child with the assistance of an adoption attorney. a child-placing agency. b. the child-placing agency having written authorization from the parent or guardian to make the temporary placement. 3. The persons interested in this proceeding are: NAME (Include father and mother if their parental rights have not been terminated.) RELATIONSHIP ADDRESS Father of Child Mother of Child Guardian of Child Prospective Parent(s) Adoption Attorney Child-Placing Agency 4. The mother of the child is a minor. The name and address of the minor mother's parent or guardian who agreed with the placement are Name Address City State Zip . The father of the child is a minor. The name and address of the minor father's parent or guardian who agreed with the placement are Name Address City State Zip . (SEE SECOND PAGE) Do not write below this line - For court use only American LegalNet, Inc. www.FormsWorkFlow.com PCA 335 (2/15) PETITION TO DETERMINE CUSTODY OF CHILD TEMPORARILY PLACED FOR ADOPTION MCL 710.23d 5. 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 6. Court, Case Number , and remains is no longer , was pending. a. I am the prosecuting attorney for this county. I have been notified that an adoption petition has not been filed and the child has not been returned to the parent or person having the right to legal custody. b. I am the prospective adoptive parent. I am unwilling or unable to proceed with the adoption. Physical custody of the child should should not be returned to the parent legal guardian agency for the following reasons: c. I am the representative of the child-placing agency that temporarily placed the child. I state that the agency is unable to proceed with adoption because of the unavailability of a parent or guardian to execute a release. the agency has legal rights to custody of the child and chooses not to proceed further with the adoption of the child by the prospective adoptive parents. the parent or guardian who authorized temporary placement desires to regain custody of the child. 7. I REQUEST that the court determine the custody of the child. Date Signature of petitioner Name of petitioner (type or print) Agency name Address City, state, and zip Telephone no. American LegalNet, Inc. www.FormsWorkFlow.com