In the matter ofDOB:, adoptee1.I have legal and physical custody of the child asmother.father.guardian pursuant to an order issued by thecourt. (Copy of order is attached.)2.I authorize, a child-placing agency, to make atemporary placement of the child with prospective adoptive parents in accordance with the Michigan Adoption Code, anda.I have read the preplacement assessment of the prospective adoptive parent(s) that was completed or updated less thana year ago and that states that the prospective adoptive parent(s) are suitable to be parent(s) of an adoptee.ORb.I have been informed that the child-placing agency must give me an opportunity to review the preplacement assessmentof the prospective adoptive parent(s) before any temporary placement.3.I have been informed that I retain full parental rights to the child and that the agency must file a petition on my behalf if I wishto regain custody of my child during the temporary placement in the adoptive home.CERTIFICATION BY PARENT/GUARDIAN OF UNEMANCIPATED MINOR PARENTI certify that I am theparentlegal guardianofwho is an unemancipated minor parent of the child. I join with the parent in authorizing the child-placing agency to make atemporary placement of the child with the prospective adoptive parents. Approved, SCAOFILE NO. PCA 329 (2/15) STATEMENT OF PARENT/GUARDIAN AUTHORIZING TEMPORARY PLACEMENTOF CHILD FOR ADOPTIONMCL 710.23b, MCL 710.23dSTATEMENT OF PARENT/GUARDIAN AUTHORIZING TEMPORARY PLACEMENT OFCHILD FOR ADOPTION Do not write below this line - For court use only Date Name of court Full name of childSTATE OF MICHIGANJUDICIAL CIRCUIT - FAMILY DIVISIONCOUNTY Signature of parent/guardianName of parent/guardian (print)Signature of parent/guardianName of parent/guardian (print)Name of witness (print)Signature of witnessName of witness (print)Signature of witnessDateSignature of parent/guardianName of parent/guardian (print)Name of witness (print)Signature of witnessAddressCityStateZipJIS CODE: ATA American LegalNet, Inc. www.FormsWorkFlow.com