Approved, SCAO JIS CODE: ASP STATE OF MICHIGAN CASE NO. PETITION NO. AFFIDAVIT OF SERVICE PERFORMED BY LAWYER-GUARDIAN AD LITEM JUDICIAL CIRCUIT - FAMILY DIVISION COUNTY Court address Court telephone no. 1. In the matter of name(s), alias(es), DOB I affirm: 2. I have met with or had contact with the child as required by the court. MCL 712A.17d(1)(d). (specify) I did not meet with or observe the child because: 3. I have reviewed the agency case file. 4. Consistent with the Michigan Rules of Professional Conduct, I have consulted with the child's parent(s) and/or guardian(s), foster care provider(s), and case worker(s). 5. I am a substitute for the appointed lawyer-guardian ad litem, I have consulted and discussed with the appointed lawyerguardian ad litem his/her visit with the child, review of the agency case file, and any discussions with the child's parent(s), guardian(s), foster care provider(s), and case worker(s). I understand that I will be paid for the services performed only if I have met with or observed the child before every proceeding or hearing as required by law. Affiant signature Address Affiant name (type or print) City, state, zip Subscribed and sworn to before me on Telephone no. , County, Michigan. Date My commission expires: Signature: Date Deputy clerk/Notary public Notary public, State of Michigan, County of NOTE: In order to receive payment, this affidavit must be prepared and attached to form MC 221, Statement of Service and Order for Payment of Court Appointed Representative. Do not write below this line - For court use only JC 82 (9/07) AFFIDAVIT OF SERVICE PERFORMED BY LAWYER-GUARDIAN AD LITEM MCL 712A.17d, MCR 3.915 American LegalNet, Inc. www.FormsWorkflow.com