In the matter of, a surrendered newborn child1.I am themotherfatherof the above named newborn child born on at.2.The newborn was surrendered to , an emergency services providerlocated at .The surrender was made by themotherfatheron, less than 28 days from filing this petition.3.The newborn is located inCounty, Michigan.I do not know where the child is presently located.4.Mother of newborn:Date of birth:Father of newborn:Date of birth:5.I wish to revoke surrender of my child and release of parental rights, if any.I REQUEST:6.That I be given custody of the child and that blood or tissue typing be ordered upon filing of this petition.7.Other:I declare that this petition has been examined by me and that its contents are true to the best of my information, knowledge, andbelief. Approved, SCAOCASE NO.STATE OF MICHIGANJUDICIAL CIRCUIT - FAMILY DIVISIONCOUNTY CCFD 03 (1/01) PETITION OF PARENT FOR CUSTODY OF SURRENDERED NEWBORN CHILD PETITION OF PARENT FOR CUSTODYOF SURRENDERED NEWBORN CHILDMCL 712.10 Full name of childDate of birth Location of birth Name of emergency services provider (indicate if unknown)Street address, city, and county of emergency services provider Do not write below this line - For court use only Signature of petitionerName (type or print)AddressCity, state, zipTelephone no.Bar no.DateTelephone no.City, state, zipAddressName (type or print) Street address, city, state, zip and county Street address, city, state, zip and county Signature of petitionerNameName Date American LegalNet, Inc. www.FormsWorkFlow.com