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Petition For Placement Order Of Surrendered Newborn Child CCFD 01 - Michigan
| Petition For Placement Order Of Surrendered Newborn Child Form. This is a Michigan form and can be used in Safe Delivery Of Newborn Statewide . |
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Approved, SCAO STATE OF MICHIGAN CASE NO. JUDICIAL CIRCUIT - FAMILY DIVISION PETITION FOR PLACEMENT ORDER COUNTY OF SURRENDERED NEWBORN CHILD In the matter of , 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 above named newborn child on . Date 2. The newborn child is believed to have been born on at Date of birth Location of birth . 3. Mother of newborn is: Date of birth: Name Street address, city, state, zip and county Father of newborn is: Date of birth: Name Street address, city, state, zip and county 4. On petitioner temporarily placed the newborn with prospective adoptive parent(s), Date residing at Name(s) Address within 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 was written (attached). verbal and is as follows: b. The parent surrendering the newborn gave the emergency service provider information. The information was written (attached). verbal and is as follows: c. Neither the emergency service provider or the parent surrendering the newborn exchanged written or verbal information because: (SEE OTHER SIDE) Do not write below this line - For court use only CCFD 01 (1/01) PETITION FOR PLACEMENT ORDER OF SURRENDERED NEWBORN CHILD MCL 712.7<<<<<<<<<********>>>>>>>>>>>>> 2I REQUEST the court to 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 related services 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. Date Attorney signature Signature of petitioner Attorney name (type or print) Bar no. Name (type or print) Address Address City, state, zip Telephone no. City, state, zip Telephone no.
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