Approved, SCAO JIS CODE: ART STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION COUNTY In the matter of CASE NO. PETITION TO ACCEPT RELEASE AND TERMINATE RIGHTS TO SURRENDERED NEWBORN CHILD , a surrendered newborn child Full name of child 1. I am an employee of , a child-placing agency that assumed Name of agency temporary protective custody of the surrendered newborn child on 2. The surrendering parent, . Date , has knowingly released the newborn. Name Evidence demonstrating this release is attached. 3. a. The nonsurrendering parent, , has been identified and located Name and provided with notice of the surrender of the newborn as follows: (Specify the address or location of the nonsurrendering parent and show proof of the notice provided.) b. The nonsurrendering parent has not been identified or located. The following efforts were made to identify, locate, and provide notice to the nonsurrendering parent of the surrender of the newborn: (Specify the efforts made.) 4. The surrendering parent nonsurrendering parent has not filed a petition for custody of the newborn within the required 28 days following notice of the surrender of the newborn. 5. I REQUEST the court to accept the release of the surrendering parent and to enter an order terminating the rights of the surrendering parent. nonsurrendering parent. I declare that this petition has been examined by me and that its contents are true to the best of my information, knowledge, and belief. Date Attorney signature Signature of petitioner Attorney name (type or print) Bar no. Address City, state, zip Name (type or print) Address Telephone no. City, state, zip Telephone no. Do not write below this line - For court use only MCL 712.17 CCFD 07 (9/07) PETITION TO ACCEPT RELEASE AND TERMINATE RIGHTS TO SURRENDERED NEWBORN CHILD American LegalNet, Inc. www.FormsWorkflow.com