Approved, SCAO Court file only STATE OF MICHIGAN CASE NO. JUDICIAL CIRCUIT - FAMILY DIVISION PETITION NO. STATEMENT OF PREFERENCE COUNTY Court address Court telephone no.1. In the matter of (name(s), alias(es), DOB) 2. The above named American Indian child has been placed with: a. a member of his or her extended family. Full name (type or print) City, county, and state b. a foster home licensed, approved, or specified by the childs tribe. Full name (type or print) City, county, and state c. other Indian foster family licensed or approved by a non-Indian licensing authority. Full name (type or print) City, county, and state d. An institution for children approved by an Indian tribe or operated by an Indian organization that has a program suitable to meet the childs needs: Full name (type or print) City, county, and state e. other non-Indian family. Full name (type or print) City, county, and state 3. The good cause for not placing the child with a family having preference under the Indian Child Welfare Act of 1978 is: Date Signature Placing agency Do not write below this line - For court use only JC 51 (6/03) STATEMENT OF PREFERENCE 25 USC 1915, MCR 3.980(C)(5)