Approved, SCAO OSM CODE: LGP STATE OF MICHIGAN FILE NO. PROBATE COURT LIMITED GUARDIANSHIP COUNTY PLACEMENT PLAN CIRCUIT COURT - FAMILY DIVISION In the matter of , a minorSpecial Note in Completing Form : Each custodial parent who signs this plan is agreeing to all the conditions of the plan even though each item refers to a singl e person. When more than one parent enters into this agreement and they differ from one another in any area of the plan, each parent must complete their own plan on separate forms. For example: If they differ in their reasons for the guardianship, each parent must specify their own reasons. NOTICE: This guardianship will not be terminated without a court finding that the termination is in the best interest of the child. This plan modifies a limited guardianship placement plan previously approved by the court. As custodial parent, I desire to establish a limited guardianship for my child and agree to the following plan: 1. The reason I want a limited guardianship is: To enable my child to attend school in the proposed guardians school district. To provide health insurance through the proposed guardian. I will be or am incarcerated until . I am currently without housing adequate for my child. I am unable to care for my child because of my health. I am unable to care for my child because of my mental instability. I desire an alternative to action recommended by child protective services. I have lost substantial control of my childs behavior. I need to improve my parenting skills. The minors physical needs for food, clothing, and housing may best be met by the proposed guardian. To comply with the requirement of the Reserves. Armed Forces. Other: 2. Visits and contact with my child will be sufficient to maintain my parent and child relationship and will be as follows: I will visit my child on: (please check each day you plan to visit)Su M Tu W Th F Sa from: (please specify the time including either a.m. or p.m.) to . I will visit my child times each week. month. Visits will occur at my residence. the proposed guardians residence. . Telephone contact will take place daily. weekly. monthly. . Letters will be sent daily. weekly. monthly. . I will attend my childs school conference provided I receive timely notice of the conference. I will attend counseling with my child. I will participate in and arrange positive outings with my child daily. weekly. monthly. . I will provide transportation for my child for . I will attend all doctor/dental appointments for my child (excluding emergencies). Transportation to and from visits with my child will be the responsibility of . Collect telephone calls will be accepted at number . Other: SEE OTHER SIDE FOR REMAINING PLANS Do not write below this line - For court use only Approved: Date Judge PC 652 (3/00) LIMITED GUARDIANSHIP PLACEMENT PLAN MCL 700.5205(2); MSA 27.15205(2), MCR 5.404(A), (B)<<<<<<<<<********>>>>>>>>>>>>> 23. Financial support will be made by me as follows: Health insurance coverage through . Policy numbers are . School lunch money, clothing, supplies. Car insurance. $ each month for room, board, miscellaneous expenses to be paid at months end. beginning. I will pay for counseling. I will pay for transportation to and from visits. I will provide food for my child as follows: I will pay for babysitting as follows: Other: 4. My plan is for the limited guardianship to continue until: The end of the current school year. I graduate my child graduates from high school. I am able to provide a drug-free household. I complete parenting classes. I am no longer incarcerated. on parole/probation. I am gainfully employed. I have established myself in a new residence. I have successfully completed drug or alcohol inpatient/outpatient treatment. I have cooperated with a substance abuse assessment and have followed the recommendations of the assessment. I have cooperated with a psychological evaluation and have followed the recommendations of the assessment. I have successfully completed psychological counseling. My child can accept my parental authority. I complete my G.E.D. job training. I no longer cohabitate with individuals. I cooperate with a domestic assault program. I have health insurance coverage for my child. I have completed my obligation to the Reserves or Armed Forces. Other: 5. I also agree as follows: As a custodial parent of the minor, I understand that if I substantially fail, without good cause, to follow this plan, my parental rights may be terminated by the court through proceedings under the juvenile code. Date Date Signature Signature Name of custodial parent (type or print) Name of custodial parent (type or print) Address Address City, state, zip Telephone no. City, state, zip Telephone no.Agreement and Acceptance of Trust by Limited Guardian I will serve as limited guardian of the minor. I agree with this plan, and I accept the trust according to the appointment and agree to file reports and to perform all duties required by law. Date Date Signature Signature Name of proposed guardian (type or print) Name of proposed guardian (type or print) Address Address City, state, zip Telephone no. City, state, zip Telephone no.