1.I am an employee of, a child-placing agency that assumedtemporary protective custody of the newborn child named above. The child was surrendered on .2.The newborn child is believed to have been born onat.3.Mother of newborn is:Date of birth:Father of newborn is:Date of birth:4.Onpetitioner temporarily placed the newborn with prospective adoptive parent(s),residing atwithin this county. Their preplacement assessment has been approved by the agency.5.a.The emergency service provider gave information (as required by MCL 712.3) to the parent surrendering the newborn.The information waswritten (attached).verbal and is as follows:b.The parent surrendering the newborn gave the emergency service provider information. The information waswritten (attached).verbal and is as follows:c.Neither the emergency service provider or the parent surrendering the newborn exchanged written or verbal informationbecause:(SEE SECOND PAGE)In the matter of, a surrendered newborn child Approved, SCAOCASE NO.STATE OF MICHIGANJUDICIAL CIRCUIT - FAMILY DIVISIONCOUNTYCCFD 01 (2/15) PETITION FOR PLACEMENT ORDER OF SURRENDERED NEWBORN CHILDPETITION FOR PLACEMENT ORDEROF SURRENDERED NEWBORN CHILDMCL 712.7 Full name of child Do not write below this line - For court use only Name of agency Date Date of birth Location of birth Street address, city, state, zip and county Street address, city, state, zip and county NameName Date Name(s) Address JIS CODE: PCS, TCS,and MiCOURT - PSN American LegalNet, Inc. www.FormsWorkFlow.com I REQUEST that the court authorize the:6.Placement of the child with the prospective adoptive parent(s).7.Child-placing agency and prospective adoptive parent(s) to provide care for the newborn.8.Prospective adoptive parent(s) to consent to all medical, surgical, dental, optical, psychological, educational, and relatedservices while having custody of the newborn.I declare that this petition has been examined by me and that its contents are true to the best of my information, knowledge, andbelief.Agency Contact Information: Signature of petitionerAttorney name (type or print)Attorney signatureAddressCity, state, zipTelephone no.Bar no.DateTelephone no.City, state, zipAddressName (type or print) Name of agency representative (type or print)AddressCity, state, zipTelephone no.Agency name E-mail American LegalNet, Inc. www.FormsWorkFlow.com