Statement Of Identifying Information {PCA 340}

Approved, SCAO JIS CODE: SII STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION FILE NO. STATEMENT OF IDENTIFYING INFORMATION COUNTY In the matter of adoptee Full name of child DOB: 1. I am assisting the parent guardian in this adoption. 2. The parties have elected not to exchange identifying information. 3. The surname and current place of residence of the adoptee are Address Name . 4. The name and address of each parent are: Name and address of mother Name and address of father 5. The name and address of the court-appointed guardian of the adoptee are Name Address . I declare that this statement has been examined by me and that its contents are true to the best of my information, knowledge, and belief. Date Signature of attorney or agency representative Name of attorney or agency representative (print) Name of firm or child-placing agency Address City, state, zip Telephone no. Bar no. Do not write below this line - For court use only PCA 340 (9/11) STATEMENT OF IDENTIFYING INFORMATION American LegalNet, Inc. www.FormsWorkFlow.com MCL 710.24(5)