Approved, SCAO JIS CODE: SNR STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION COUNTY STATEMENT OF NONRESIDENT PROSPECTIVE ADOPTIVE PARENT TRANSFERRING PHYSICAL CUSTODY OF CHILD FOR ADOPTION FILE NO. In the matter of Full name of child DOB: 1. Physical custody of the child was transferred to me on 2. I am a prospective adoptive parent and a resident of Date . . I agree to obtain approval in State compliance with the Interstate Compact on Placement of Children before the child is sent, brought, or caused to be sent or brought into 3. Temporary domicile is in City, state, and zip . I agree to submit to the jurisdiction of the State of Michigan. County, Michigan at . Address 4. The temporary placement will not become formal until both parents consent to adoption or release their parental rights and the court orders the termination of parental rights of both parents and approves the placement. 5. I understand if the court enters an order directing return of the child to the parent or guardian with legal custody, I must return physical custody of the child to the parent or guardian named in the order within 24 hours of being served with the court order. Date Signature of prospective adoptive parent Name of prospective adoptive parent (print) Signature of prospective adoptive parent Name of prospective adoptive parent (print) Address City, state, and zip Signature of witness Name of witness (print) Do not write below this line - For court use only PCA 332a (2/15) STATEMENT OF NONRESIDENT PROSPECTIVE ADOPTIVE PARENT TRANSFERRING PHYSICAL CUSTODY OF CHILD FOR ADOPTION MCL 710.23d American LegalNet, Inc. www.FormsWorkFlow.com