Statement Of Services Performed By Attorney {PCA 346}

Approved, SCAO STATE OF MICHIGAN STATEMENT OF SERVICES FILE NO. JUDICIAL CIRCUIT - FAMILY DIVISION PERFORMED BY ATTORNEY COUNTY 7 DAY 21 DAY In the matter of adoptee DOB: Full name of child I am an attorney representing the petitioner mother petitioner father mother of adoptee father of adopteeI state that the following itemizes the services performed and any fees, compensation, or other thing of value received by or agreedto be paid to me for, or incidental to, the adoption of the child. Date Service Performed Fee, Compensation, or Other Value SUBTOTAL from 7 Day Statement of Services Performed by Attorney TOTAL I represent a party in this direct placement adoption. I have not requested or received any compensation for the activities described in MCL 710.54(2); MSA 27.3178(555.54)(2). I delcare 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 attorney Name (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 PCA 346 (9/97) STATEMENT OF SERVICES PERFORMED BY ATTORNEY MCL 710.54(7); MSA 27.3178(555.54)(7)