Adoption Services Face Sheet

OAKLAND COUNTY FAMILY COURT ADOPTION SERVICES FACE SHEET FROM: (A gency, Attorney, Etc.) SECTION 1 226 ADOPTIVE FAMILY 226 MCL 710.23 NAME (Last, First, and Middle 226 Use Mr., Mrs., Miss, or Ms.) NAME OF SPOUSE (Fir st, Middle, Last) MAIDEN NAME DATE OF MARRIAGE AND PLACE ADDRESS ( Number and Street or RFD) CITY OR TOWN STATE ZIP CODE COUNTY TELEPHONE # PERSONAL CHARACTERISTICS AND BACKGROUND DATE OF BIRTH RACE DATE OF BIRT H RACE CITY, STATE OF BIRTH CITY, STATE OF BIRTH PREVIOUS MARRIAGE PREVIOUS MARRIAGE IF YES, DATE OF MARRIAGE IF YES, DATE OF MARRIAGE DATE MARRIAGE TERMINATED HOW MARRIAGE TERMINATED DATE MARRIAGE TERMINATED HOW MARRIAGE TERMINATED CHILDREN PRESENTLY IN HOUSEHOLD OTHER PERSONS LIVING I N HOUSEHOLD OR DEPENDENTS NAME DATE OF BIRTH NAME DATE OF BIRTH Adoption Face Sheet 226 Page 1 of 2 Rev. March 2014 American LegalNet, Inc. www.FormsWorkFlow.com OAKLAND COUNTY FAMILY COURT ADOPTION SERVICES FACE SHEET SECTION II 226 CHILD TO BE ADOPTED 226 MCL 710.27 ( Birth Family Information) NAME OF CHILD (First, Middle, Last) TO BE CHANGED TO DATE OF BIRTH (Mo, Day, Year) VERIFICATION ATTACHED Yes No SEX RACE MCI WARD YES NO CITY,STATE OF BIRTH COMMITTING COUNTY COMPETING PARTY YES NO NAME OF MOTHER AT TIME OF CHILD222S BIRTH NAME OF MOTHER AT THIS TIME RACE D.O.B. ADDRESS NAME OF PUTATIVE FATHER RACE D.O.B. ADDRESS NAME OF LEGAL FATHER RACE D.O.B. ADDRESS SIBLINGS OF CHILD NAME DATE OF BIRTH PLACEMENT THIS REPORT REPRESENTS THE RESULTS OF THE STUDY OF THE ABOVE FAMILY AND CHILD PREPARED BY: (Signature) (Title 226 Social Worker, Attorney, Etc.) DATE TYPE/PRINT NAME PHONE # Adoption Face Sheet 226 Page 2 of 2 Rev. March 2014 American LegalNet, Inc. www.FormsWorkFlow.com