Approved, SCAO JIS CODE: RCG STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION FILE NO. RELEASE OF CHILD BY GUARDIAN COUNTY In the matter of Full name of child 1. I, Name , am the court-appointed guardian for the child named above. the parent of the child named above. at Date Place The child named above was born . 2. I have authority to sign this release of the child named above for adoption by order of the Court (a copy of the order is attached and a copy of my current letters of guardianship are attached). 3. a. A judge or referee of the court, or other authorized person, has fully explained to me my legal rights as guardian and the legal rights of the parent(s) of the child named above and that I do not have to sign this release. I understand that if I do sign this release, my rights as guardian and the legal rights of each parent will be terminated. b. A judge or referee of the court, or other authorized person, has fully explained to me, as guardian of the parent, the legal rights of the parent to the child named above and that I do not have to sign this release. I understand that if I do sign this release, I voluntarily and permanently give up, on behalf of the parent, his/her parental rights to the child. 4. I have not received or been promised any money or anything of value for the release of the child, except for charges and fees approved by the court. 5. I understand my rights as guardian and the rights of the parent(s) to the child and the right to request a rehearing or to appeal within 21 days after an order is entered terminating the rights of the parent(s) and of myself as guardian. 6. a. As guardian of the child named above, I voluntarily and permanently give up my rights as guardian and the rights of each parent to the child named above. b. As guardian of the parent and on his/her behalf, I voluntarily and permanently give up his/her parental rights to the child named above. I release the child to Child-placing agency or Michigan Department of Health and Human Services for the purpose of adoption. Date Guardian signature Guardian name (type or print) Address City State Zip See reverse side for certification by judge/referee Do not write below this line - For court use only American LegalNet, Inc. www.FormsWorkFlow.com PCA 305a (2/15) RELEASE OF CHILD BY GUARDIAN MCL 700.431(1)(c), MCL 710.28, MCL 710.29, MCL 710.54, MCR 3.801 NOTE: Before taking the release, the court shall obtain from the parent(s) all the nonidentifying information required by MCL 710.27. CERTIFICATION BY JUDGE/REFEREE An investigation of this release has been made. At a hearing where a verbatim record of testimony was made, I explained to a. the guardian of the child his/her legal rights and that by signing this release, the guardian was voluntarily and permanently giving up his/her rights to the child. b. the guardian of the parent the parent's legal rights and that by signing this release, the guardian was voluntarily and permanently giving up, on behalf of the parent, his/her parental rights to the child. The guardian then voluntarily signed this release before me. The child named above is over five years of age, and the court finds that the child is best served by this release. Date Judge/Referee Bar no. American LegalNet, Inc. www.FormsWorkFlow.com