Out Of Court Consent To Direct Placement Adoption By Parent {PCA 355}

In the matter of Full name of child , adoptee þ USE NOTE: This consent cannot be signed until at least 72 hours after the birth of the adoptee. This form is not for use in cases involving an Indian child as defined by MCR 3.002(12).1. þ I am the þ mother þ father þ of the child named above. My date of birth is .2. þ The child named above was born on Date of birth at Time at Place .3. þ I also state: (Write your initials before each item to show you agree with the statement.) þ Initial þ a. þ I have read or had read to me each of my rights as a parent that are described in MCL 710.44(8)(c), and I þ understand these rights. þ þ Initial þ b. þ This child is not an Indian child according to MCR 3.002(12) and is not eligible for membership in any Indian tribe. þ þ Initial þ c. þ I am signing this out-of-court consent as a free and voluntary act and I have been advised that I cannot be forced þ to sign this out-of-court consent for any reason. þ Initial þ d. þ I have not been given or promised any money or other thing of value in exchange for signing this out-of-court þ þ consent. þ Initial þ e. þ If I sign this out-of-court consent, I understand that I am giving up all my parental rights and authorizing the court þ to permanently terminate all my parental rights, unless the court allows me to revoke my out-of-court consent. þ Initial þ f. þ It has been explained to me and I understand all the following: þ i. þ I am not required to sign an out-of-court consent. þ ii. þ I may make a temporary placement of my child with the prospective adoptive parent or parents, if I have not þ already done so, or I may continue the temporary placement I have already made, until I choose to sign a þ consent in court or sign an out-of-court consent. þ iii. þ My obligation to support the child continues until a court of competent jurisdiction modifies or terminates the þ obligation, an order of adoption is entered, or the child is emancipated by operation of law. þ iv. I may request revocation of the out-of-court consent I have signed by submitting a timely written request for þ revocation. þ v. þ If I request a revocation of the out-of-court consent, I must appear before the court so the court may consider þ whether to grant the revocation. þ Initial þ g. þ I have been advised that I may submit a request for revocation in writing to the adoption attorney or child-placing þ agency that accepted the out-of-court consent not more than 5 days, excluding weekends and holidays, after the þ out-of-court consent was signed, or I may petition the court on my own for revocation of the out-of-court consent þ not more than 5 days, excluding weekends and holidays, after the out-of-court consent was signed. þ Initial þ h. þ If I submit a timely request or file a timely petition for revocation, the court may grant the request or deny the þ þ request depending on my fitness and immediate ability to properly care for the child and whether the best interests þ of the child would be served by the revocation.4. þ I relinquish all my parental rights to my child, including, but not limited to: þ a. þ The right to have or to seek care and custody of the child. þ b. þ The right to have or to seek parenting time with the child. þ c. þ The right to inherit from the child or have the child inherit from me. þ d. þ The right to services and earnings from the child. þ e. þ The right to determine the child222s schooling, religious training, and parenting practices. American LegalNet, Inc. www.FormsWorkFlow.com Out-of-Court Consent to Direct Placement Adoption by Parent þ (5/18) þ Page of File No. 5. þ I voluntarily and permanently give up all my parental rights to my child for adoptive placement with þ þ a. þ The petitioner(s), who have filed or intend to file a petition for the adoption of the adoptee and whose name(s) is/are þ unknown to me because identifying information is not being exchanged. þ þ b. þ Adoptive parent(s) name(s) , who filed or intend to file a petition for the þ þ adoption of my child.6. þ I acknowledge that I am signing this out-of-court consent freely and voluntarily, after my parental rights have been explained þ to me and any questions I may have about it have been fully answered. I understand the rights I am giving up and that an þ þ order terminating my parental rights, when entered by the court, is a permanent termination of all my parental rights. Date þ Parent signature þ Parent name (type or print) Address City State Zip þ parent þ The parent signing this consent is an unemancipated minor. I am the þ guardian (Copy of letters of authority attached.) þ guardian ad litem (Copy of order attached.) þ of the minor parent, and I join with the minor parent in signing this consent. Date þ Parent/guardian/guardian ad litem of unemancipated minor signature Address City State ZipI acknowledge that I have been provided a copy of this form: þ Parent signatureThis out-of-court consent was signed in front of me by the parent named above and, if this out-of-court consent involves a parentwho is an unemancipated minor, by the parent or guardian of the unemancipated minor: Adoption attorney signature þ Adoption agency representative signature Adoption attorney name (type or print) þ Name of adoption agency representative (type or print) þ Name of adoption agency (type or print)A request for revocation of this out-of-court consent may be submitted to the adoption attorney who witnessed it or to the child-placing agency that accepted it by mail, fax, or e-mail.Adoption attorney222s contact information: Adoption attorney222s name (type or print) Address City State Zip Adoption attorney222s e-mail address Adoption attorney222s fax numberChild-placing agency contact information: Child-placing agency222s name and name of caseworker (type or print) Address City State Zip Child-placing agency222s e-mail address Child-placing agency222s fax numberWITNESS STATEMENT CONTACT INFORMATION FOR REQUESTING REVOCATION OF THIS OUT-OF-COURT CONSENT . www.FormsWorkFlow.com