Approved, SCAO JIS CODE: RQC STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION FILE NO. COUNTY Court address REQUEST FOR CONFIDENTIALITY Court telephone no. In the matter of Full name of child 1. The minor is an Indian child as defined in MCR 3.002(5) and either is eligible to be placed for adoption or presently is in an adoptive placement. 2. I, Name , am the child's natural father and ask that my identity be kept confidential. 3. I, Name , am the child's natural mother and ask that my identity be kept confidential. Signature Subscribed and sworn to before me on My commission expires: Date Date , Signature: Deputy clerk/Notary public County, Michigan. Notary public, State of Michigan, County of Use note to court: This request must be sent to the Secretary of the Interior with the final order of adoption if the minor is adopted. Do not write below this line - For court use only PCA 353 (3/10) REQUEST FOR CONFIDENTIALITY 25 USC 1951(c) American LegalNet, Inc. www.FormsWorkFlow.com