Release Of Child By Child Placing Agency {PCA 306}

Approved, SCAO STATE OF MICHIGAN FILE NO. JUDICIAL CIRCUIT - FAMILY DIVISION RELEASE OF CHILD BY COUNTY CHILD PLACING AGENCY In the matter of DOB: , adoptee Full name of child I, , on behalf of Name of representative Name of child placing agency voluntarily release and relinquish parental rights to the above named child to the Michigan Family Independence Agency for the purpose of adoption or suitable placement. I am the duly authorized representative of the child placing agency. Signature Title Subscribed and sworn to before me on in County, Michigan. Date My commission expires: Signature: Date Notary public Do not write below this line - For court use only MCL 710.28; MSA 27.3178(555.28),PCA 306 (9/97) RELEASE OF CHILD BY CHILD PLACING AGENCY MCL 710.29; MSA 27.3178(555.29), MCR 5.751