Statement Of Services Performed By Agency Or Family Independence Agency {PCA 345}

Approved, SCAO STATE OF MICHIGAN STATEMENT OF SERVICES FILE NO. JUDICIAL CIRCUIT - FAMILY DIVISION PERFORMED BY AGENCY/ COUNTY FAMILY INDEPENDENCE AGENCY 7 DAY 21 DAY In the matter of adoptee DOB: Full name of child I state that the following itemizes the services performed and any fee, compensation, or other thing of value received by or agreedto be paid to the child placing agency or the Michigan Family Independence Agency for, or incidental to, the adoption of the child.(NOTE: If no fee, compensation, or other thing of value is paid or agreed to be paid, you must write "NONE" in the fee column.) Date Service Performed Fee, Compensation, or Other Value SUBTOTAL from 7 Day Statement of Services Performed by Agency TOTAL The child placing agency or Michigan Family Independence Agency has not requested or received any compensation for the activities described in MCL 710.54(2); MSA 27.3178(555.54)(2). I am a representative of the child placing agency/Michigan Family Independence Agency and have authority to make this statement.I declare that this statement has been examined by me and that its contents are true to the best of my information, knowledge, andbelief. Date Signature of child placing agency/FIA representative Name (print or type) Name of agency (print or type) NOTE: Attach this statement to Form PCA 347, "Petitioners Verified Accounting" Address City, state, zip Telephone no. Do not write below this line - For court use only MCL 710.54(7); MSA 27.3178(555.54)(7)PCA 345 (9/97) STATEMENT OF SERVICES PERFORMED BY AGENCY/FAMILY INDEPENDENCE AGENCY