Approved, SCAO JIS CODE: PCS, TCS, and MiCOURT - RCP STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION FILE NO. RELEASE OF CHILD BY PARENT COUNTY In the matter of Full name of child NOTE: If the child is an Indian child use form PCA 305-I. 1. I, Name Date , am the at Place mother (Date of birth father (Date of birth ) ) . of the child named above, who was born 2. A judge or referee of the court, or other authorized person, has fully explained to me my legal rights as a parent and that I do not have to sign this release of my parental rights. I understand my parental rights and that if I do sign this release, I voluntarily and permanently give up all of my parental rights to my child. 3. I understand my right to request a rehearing or to appeal within 21 days after an order is entered terminating my parental rights. 4. I have not received or been promised any money or anything of value for the release of my child except for charges and fees approved by the court. 5. Of my own free will, I give up completely and permanently my parental rights to my child, and I release my child to Child-placing agency or Michigan Department of Health and Human Services for the purpose of adoption. Date Parent signature Parent name (type or print) Address City State Zip The parent signing this release is an unemancipated minor. I am the of the minor parent, and I join with the minor parent in signing this release. parent guardian (Copy of letters of authority attached.) guardian ad litem (Copy of order attached.) Date Parent/guardian of unemancipated minor signature Address City State Zip See reverse side for certification by judge/referee and special acknowledgment for releases by those in the armed services or in prison. Do not write below this line - For court use only PCA 305 (2/15) RELEASE OF CHILD BY PARENT American LegalNet, Inc. www.FormsWorkFlow.com 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 the parent her/his legal rights and that, by signing this release, s/he was voluntarily and permanently giving up her/his parental rights to the child. The parent then voluntarily signed this release before me. The parent, guardian, or guardian ad litem of the unemancipated minor parent was present during this hearing and voluntarily signed this release before me. The child named above is over 5 years of age, and the court finds that the child is best served by this release. Date Judge/Referee Bar no. In addition to completing the other side of this release, if the parent signing this release is in the armed services or is in prison, the following special acknowledgment must be completed by a person authorized by law to administer oaths. SPECIAL ACKNOWLEDGMENT I certify and acknowledge that is presently Address Name of parent is personally known to me, at Name of place State Zip confined stationed located at and stated City that s/he is the mother father of the child. I fully explained her/his legal rights as a parent, that s/he did not have to sign this release of her/his parental rights, and that if s/he did sign this release, s/he would be voluntarily and permanently giving up her/his parental rights to the child for purposes of adoption. I also explained her/his right to a rehearing or to appeal within 21 days after an order is entered terminating her/his parental rights. The parent then voluntarily signed this release. Subscribed and sworn to before me on My commission expires: Date Date , Signature: County and state . Notary public, State of Michigan, County of Notary Public: Name (type or print) Address City, state, zip American LegalNet, Inc. www.FormsWorkFlow.com