In the matter of
DOB:
, adoptee
1. I,
, on behalf of
voluntarily consent to the adoption of the child named above by
as requested in a petition on file or to be filed in court.
2. I am a representative authorized to execute this consent.
Subscribed and sworn to before me on
, in
County, Michigan.
My commission expires:
Signature:
*The consenting party in item 1 must be one of the following:
1. A representative authorized to consent on behalf of the Michigan Department of Human Services or of a child-placing agency
to whom the child has been permanently committed by an order of the family division of the circuit court.
2. The family division of the circuit court having permanent custody of the child.
3. A representative authorized to consent on behalf of the Michigan Department of Human Services or of a child-placing agency
to whom the child has been released.
4. A representative authorized to consent on behalf of a child-placing agency of another state or county, which has authority to
consent to the adoption.
5. An individual or official authorized by tribal law or order of the tribal court to give consent.
PCA 309 (9/07) CONSENT TO ADOPTION BY AGENCY/COURT
Approved, SCAO
FILE NO.
Do not write below this line - For court use only
Full name of child
CONSENT TO ADOPTION BY
AGENCY/COURT
Date
Date
Notary public
Title
Signature
*Name of agency or court
*Name
STATE OF MICHIGAN
JUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY
MCL 710.43, MCL 710.44, MCR 3.801
Date
JIS CODE: CAD