Statement Of Services Performed By Agency Or Family Independence Agency
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Statement Of Services Performed By Agency Or Family Independence Agency Form. This is a Michigan form and can be use in Adoption Statewide.
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Tags: Statement Of Services Performed By Agency Or Family Independence Agency, PCA 345, Michigan Statewide, Adoption
JIS CODE: VSD
Approved, SCAO
STATE OF MICHIGAN
JUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY
In the matter of adoptee
STATEMENT OF SERVICES
PERFORMED BY AGENCY/
DEPARTMENT OF HUMAN SERVICES
7-DAY
21-DAY
FILE NO.
DOB:
Full name of child
I state that the following list itemizes the services performed and any fee, compensation, or other thing of value received by or agreed
to be paid to the child-placing agency or the Michigan Department of Human Services for, or incidental to, the adoption of the child.
(NOTE: If no fee, compensation, or other thing of value is paid or agreed to be paid, you must write "NONE" in the fee column.)
Date
Service Performed
Fee, Compensation, or Other Value
SUBTOTAL from 7-Day Statement of Services Performed by Agency
TOTAL
The child-placing agency or Michigan Department of Human Services has not requested or received any compensation for the
activities described in MCL 710.54(2).
I am a representative of the child-placing agency/Michigan Department of Human Services and have authority to make this
statement. I declare that this statement has been examined by me and that its contents are true to the best of my information,
knowledge, and belief.
Date
Signature of child-placing agency/DHS representative
Name (print or type)
NOTE: Attach this statement to form PCA 347,
"Petitioner's Verified Accounting"
Name of agency (print or type)
Address
City, state, zip
Telephone no.
Do not write below this line - For court use only
MCL 710.54(7)
PCA 345 (9/07)
STATEMENT OF SERVICES PERFORMED BY AGENCY/DEPARTMENT OF HUMAN SERVICES
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