Approved, SCAO JIS CODE: TCA STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION COUNTY STATEMENT OF PARENT/GUARDIAN TRANSFERRING PHYSICAL CUSTODY OF CHILD FOR ADOPTION FILE NO. In the matter of the 1. I am a Full name of child DOB: with legal and physical custody of the child and am being assisted in the temporary . (Attach copy of current letters of authority.) parent guardian placement of the child by 2. On Date Name of adoption attorney or agency , for the purpose of adoption, physical custody of the child was transferred to: Name(s) of parent(s) City a. prospective adoptive parent(s) County at who reside(s) in . Street address Zip b. Unknown to me because full identifying information is not being exchanged. 3. I understand that I retain full parental rights to my child. I agree that the prospective adoptive parent may consent to all medical, surgical, psychological, educational, and related services for my child during the temporary placement. 4. I understand that this temporary placement may be revoked by me by filing a petition in this court requesting that my child be returned to me. 5. I have read a preplacement assessment of the prospective adoptive parent(s) that was completed or updated less than a year ago and which states that the prospective adoptive parent(s) are suitable to be parents of an adoptee. 6. The names and addresses of the mother and father are: Mother: Name Street address City State Zip . She is a minor. The name and address of the minor mother's parent or guardian who agreed with the placement are Name(s) Street address City Street address City State State Zip Zip . . Father: Name He is a minor. The name and address of the minor father's parent or guardian who agreed with the placement are Name(s) . Street address City State Zip (PLEASE SEE OTHER SIDE) Do not write below this line - For court use only MCL 710.23d PCA 330 (2/15) STATEMENT OF PARENT/GUARDIAN TRANSFERRING PHYSICAL CUSTODY OF CHILD FOR ADOPTION American LegalNet, Inc. www.FormsWorkFlow.com 6. continued. The name and address of each other possible putative father is . Date Signature of parent/guardian/agency official Name of parent/guardian/agency official (print) Signature of parent/guardian/agency Name of parent/guardian/agency official (print) Signature of witness Name of witness (print) Signature of witness Name of witness (print) CERTIFICATION BY PARENT/GUARDIAN OF UNEMANCIPATED MINOR PARENT I certify that I am the parent legal guardian of Name of parent of child , who is an unemancipated minor parent of the child. I have reviewed this statement and agree with the temporary placement. Date Signature of parent/guardian Name of parent/guardian (print) Address City, state, and zip Signature of witness Name of witness (print) REPORT TO COURT FOLLOWING TEMPORARY PLACEMENT I report that I am assisting in the temporary placement of a child who was placed for purposes of adoption in the home of adoptive parents as set forth in this statement. The statement of the prospective adoptive parents evidencing transfer of physical custody of the child to them is attached. The parent(s) and prospective adoptive parent(s) have elected not to exchange full identifying information. The name(s) and address(es) of the prospective adoptive parent(s) are Name(s) . Street address City State Zip Date Name of attorney or agency representative (print) Name of firm or agency Signature of attorney or agency representative Address City, state, and zip American LegalNet, Inc. www.FormsWorkFlow.com