Approved, SCAO
JIS CODE: PRC
STATE OF MICHIGAN
JUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY
PETITION BY PARENT/GUARDIAN FOR RETURN OF CHILD AND EX PARTE ORDER
FILE NO.
In the matter of 1.I am the
Full name of child
DOB: with the right to legal and physical custody of the child. a child-placing agency in temporarily placing the child in the home of
parent
legal guardian
2. I was assisted by an adoption attorney prospective adoptive parents. 3. The persons interested in this proceeding are:
NAME
RELATIONSHIP
ADDRESS
Father of Child Mother of Child Guardian of Child Prospective Parent(s) Adoption Attorney Child-Placing Agency 4. I REQUEST that the temporary placement be revoked and that the court issue an ex parte order directing the prospective adoptive parents to immediately return the child to me. I declare that this petition has been examined by me and that its contents are true to the best of my information, knowledge, and belief.
Date Signature of parent Signature of parent
CONSENT TO RETURN OF CHILD I am a prospective adoptive parent and I presently have physical custody of the child. The parent or guardian of the child has requested that physical custody of the child be returned to him/her and that the temporary placement of the child with me be revoked. I consent to the return of the child to the parent or guardian.
Date Signature of prospective adoptive parent Signature of prospective adoptive parent
(PLEASE SEE OTHER SIDE)
Do not write below this line - For court use only
MCL 710.23d, MCL 710.23e PCA 337 (9/07)
PETITION BY PARENT/GUARDIAN FOR RETURN OF CHILD AND EX PARTE ORDER
EX PARTE ORDER Date of Entry: Judge:
Bar no.
IT IS ORDERED that the prospective adoptive parent(s),
Name(s)
,
Name
shall return the child within 24 hours of receipt of this order to the parent/guardian with authority for legal and physical custody of the child.
Judge