ROY C. HAYES Ill CIRCUIT JUDGE 231•47·7243 F 231 ·47•72+4 [email protected]To Adopting Parents: jtnf 1 of�it4ign 33RD JUDICIAL CIRCUIT � § COUN BUILDING 301 STATE STREET CHARLEVOIX, MICHIGAN 43720 VALERIE K. SNYDER PRESIDING FAMILY DIVISION JUDGE 231·47·7214 FAX 231·47·72 Attached you will find the necessary rms needed to commence adoption proceedings. The Petition r Adoption, Application, Records Check Release, Release of Information, and Petitioner's Verified Accounting are to be completed in ink or� and retued to this office. (If you "x" No. 9 of the Petition r Adoption, you will also need to complete and retu the attached Supplemental Petition.) Along wi e above-mentioned rms, the llowing should also be filed: 1) A copy of the child's birth certificate. 2) A copy of your marriage license. 3) A copy of Acknowledgement of Pateity (if any). 4) Copies of Order of Filiation, Order r Support/Visitation, and other peinent documents (if any). 5) All copies of Divorce Judgments and Subsequent Orders (if any). 6) A certified copy of death certificate (if parent is deceased). 7) $187.00 filing e ($175 Petition e; $12 certified copy of Order of Adoption). 8) A detailed map to your home r an In-Family Adoption Investigation. (The court worker will contact you r a date and time r this investigation.) THE PETITIONERS MUST BE RESENTS OF CHARLEVOIX COUNTY Pending the finalization of the adoption, the llowing documents will be needed: Petitioner's Verified Accounting - 21 day (PCA 3 47) and e Adoption Report. Additional documents are required with rerence to termination of the putative ther's/ non-custodial parent's/guardian's rights. If the adoption is contested, it is recommended you consult with an attoey. The filing e is $187.00 r each child, made payable to Charlevoix Probate Court. The adoption process is usually completed within six months. (At e time of finalizing the adoption, there will be an additional e of $40.00 r each child's new birth certificate. A check or money order -- no cash -- r this amount should be made payable to the State of Michigan. If the child was bo outside the State of Michigan, the e will vary.)
Attached you will find the necessary forms needed to commence adoption proceedings. The Petition for Adoption, Application, Records Check Release, Release of Information, and Petitioner's Verified Accounting are to be completed in ink or� and returned to this office. (If you "x" No. 9 of the Petition for Adoption, you will also need to complete and return the attached Supplemental Petition.)
Along with the above-mentioned forms, the following should also be filed:
1) A copy of the child's birth certificate.2) A copy of your marriage license.3) A copy of Acknowledgement of Paternity (if any).4) Copies of Order of Filiation, Order for Support/Visitation, and other pertinent documents (if any).5) All copies of Divorce Judgments and Subsequent Orders (if any).6) A certified copy of death certificate (if parent is deceased).7) $187.00 filing fee ($175 Petition fee; $12 certified copy of Order of Adoption).8) A detailed map to your home for an In-Family Adoption Investigation. (The court worker will
contact you for a date and time for this investigation.)
THE PETITIONERS MUST BE RESIDENTS OF CHARLEVOIX COUNTY
Pending the finalization of the adoption, the following documents will be needed: Petitioner's Verified Accounting - 21 day (PCA 34 7) and the Adoption Report.
Additional documents are required with reference to termination of the putative father's/non-custodial parent's/guardian's rights. If the adoption is contested, it is recommended you consult with an attorney.
The filing fee is $187.00 for each child, made payable to Charlevoix Probate Court. The adoption process is usually completed within six months. (At the time of finalizing the adoption, there will be an additional fee of $40.00 for each child's new birth certificate. A check or money order -- no cash -- for this amount should be made payable to the State of Michigan. If the child was born outside the State of Michigan, the fee will vary.)
After completing the above information, please contact this office for an appointment at 547-7214.
Encls: Petition for Adoption, Form PCA 301
Sincerely,
Heather McCully
Heather McCullyProbate Register
Adoption Application; Records Check Release; Release of Information Petitioner's Verified Accounting (2), Form PCA 347 Supplemental Petition, Form PCA 302 Adoption Report
Packets/ Adoption
01/13
1
ADOPTION APPLICATION
CHILD TO BE ADOPTED
ADOPTEE
Full name of child presently_______________________________________________________________________ first middle last
Name to be changed to__________________________________________________________________________ first middle last
Date of birth________________________________Social Security #_____________________________________________
Birthplace___________________________________________________________________________________ hospital name city state
Names and dates of shots given to child up to present date and by whom: __________________________________________________________________________________________
How does the child feel about the adoptive parent(s) and adoption? (Use backside if necessary) __________________________________________________________________________________________
Full name_________________________________________________Maiden name_________________________ first middle last
Address____________________________________________________________Date of birth________________ street / p.o. box city/state number of years at this address
Full name___________________________________________________________________________________ first middle last
Address_________________________________________________________Date of birth________________ street/p.o. box city/state number of years at this address
Birthplace___________________________ Nationality____________Race ________________Religion_______________ hospital name city/state
Military service_________________________Marriage date_____________________________________________ from to date city/state
Past Marriages________________________________________________________________________________date(s) city(ies) / state(s)
All divorce dates and counties finalized_______________________________________________________________
Employment___________________________________________________Work phone__________________ place address
Number of years at present job____________Gross income for year__________________Education__________________ grade completed
High school attended_____________________________________College attended____________________________ name city/state name
I filed a petition to adopt the adoptee. This accounting is a complete itemization of payments/disbursements of money or anythingof value made or agreed to be made by me or on my behalf in connection with this adoption as of this date. Form PCA 347a willbe submitted to report any additional payments/disbursements of money or anything of value made or agreed to be made by meor on my behalf in connection with this adoption.
EXPENSES TOTAL
1. Court Filing FeePetition for Adoption ................................................................................................. $Order of Adoption ..................................................................................................... $Motion for Early Confirmation .................................................................................... $Birth Certificate Fee .................................................................................................. $Other petitions, motions, orders ................................................................................ $ $
2. Agency/Michigan Department of Health and Human Services Charges (itemized on other side of this form) $
3. Attorney Fees (itemized on other side of this form) .................................................................................. $
4. Travel Expenses (itemized on other side of this form) .............................................................................. $
5. Medical, Hospital, Nursing, or Pharmaceutical Expenses (itemized on other side of this form) ................ $
6. Counseling Services (itemized on other side of this form) ........................................................................ $
7. Living Expenses (itemized on other side of this form) .............................................................................. $
8. Information Gathering Expenses (itemized on other side of this form) ..................................................... $
9. Other (itemized on other side of this form) ................................................................................................. $
I REQUEST that the court approve these payments and disbursements. TOTAL $
I declare that this accounting and the attachments have been examined by me and that the contents are true to the best of myinformation, knowledge, and belief.
NOTE: This accounting must be filed at least 7 days before formal placement for adoption.
Approved, SCAO
FILE NO.
PCA 347 (3/16) PETITIONER'S VERIFIED ACCOUNTING
Full name of child
MCL 710.54(7), MCR 3.803(A)
PETITIONER'S VERIFIED ACCOUNTING
Telephone no.
Date
Telephone no.
Do not write below this line - For court use only
STATE OF MICHIGANJUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY
Address
City, state, zip
Name (print or type)
Signature of petitioner
Address
City, state, zip
Name (print or type)
Signature of petitioner
JIS CODE: PCS and MiCOURT - PVA TCS - PVA7
ITEMIZED ACCOUNTING OF PAYMENTS/DISBURSEMENTS
Instructions: The following are types of expenses that must be itemized. Each type of expense is explained. For each type, identifythe type by number, list each expense in that type separately, total the amounts, and place the total under the same type numberon the front of this form. If the space provided below is not adequate, make copies before writing any information on this form. Writein the date for each payment made, the amount of that payment, who that payment was made to, and the purpose of the paymentfor the following types. You must attach a receipt for each payment/disbursement.Type 2. Agency Charges - fees and expenses charged by and to be paid to the agency.Type 3. Attorney Fees - fees and expenses charged by and to be paid to the attorney.Type 4. Travel Expenses - expenses associated with travel that are necessary to the adoption.Type 5. Medical Expenses - expenses connected with the birth of the child or illness of the child not covered by the birth parent's
health care benefits or Medicaid.Type 6. Counseling Expenses - expenses for counseling related to the adoption for the parent, guardian, or adoptee.Type 7. Living Expenses - expenses of the mother before the birth of the child and for no more than six weeks after the birth.Type 8. Information Gathering Expenses - expenses for getting required information about the adoptee and the adoptee's
biological family.Type 9. Other - includes copy costs, process server fees, etc.
TYPE NO. DATE AMOUNT NAME AND ADDRESS OF RECIPIENT PURPOSE
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
RECORDS CHECK RELEASE
Please be informed that the Charlevoix County 33rd Circuit Court - Family Division routinely completes investigations as required by law to prepare written reports for recommendations to the court. Pursuant to this requirement, it is the policy of this court to complete a Central Registry check and a criminal/driving history check. Please provide the following information regarding the proposed guardian/standby guardian.
NAME: ------------------------------
LAST FIRST MIDDLE NAME (NOT JUST INITIAL)
MAIDEN NAME/NAME(S) PREVIOUSLY USED: ___________ _
DATE OF BIRTH: ______ RACE: ________ SEX: ____ _
SOCIAL SECURITY#:------ DRIVER'S LICENSE# ______ _
I authorize the Charlevoix County th Probate Court to request information from the Michigan Department of Human Services or any agency as may be appropriate and also authorize a criminal/driving history check.
Signature of proposed guardian/standby guardian Date
Street Address
City State Zip
Phone No. / Cell Phone No.
Y:\Prob111c Fonns\Rccord Checks P\RECORD CHECK RELEASE FORMS\ADUL T GDN.doc l l!Jfl 5
Cyndie’sProbateForms:MiscForms/Release of Information form 04/06
RELEASE OF INFORMATION
NAME OF CHILD: ______________________________DOB: _______________________
I request that any information including agency records, school records, medical records, and all other records by agencies of other facilities be released to the Charlevoix County Probate Court.
_____________________________________________________________ ____________________________ signature date
_____________________________________________________________ ____________________________ signature date
_____________________________________________________________ ____________________________ signature of witness date
VALERIE K. SNYDER
Approved, SCAO
In the matter of Full name of child
DOB: , adoptee adoptee is an Indian child
JIS CODE:SPT
Do not write below this line - For court use only
STATE OF MICHIGANJUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY
SUPPLEMENTAL PETITION AND AFFIDAVIT TO TERMINATE
PARENTAL RIGHTS(STEPPARENT ADOPTION)
FILE NO.
PCA 302 (6/17) SUPPLEMENTAL PETITION AND AFFIDAVIT TO TERMINATE PARENTAL RIGHTS (STEPPARENT ADOPTION) MCL 710.26, MCL 710.51(6), MCL 712B.9(1), MCR 3.801
(SEE SECOND PAGE)
I, Name of petitioning parent
, request that the parental rights of
Name (type or print) , the other parent of the child, be terminated
because of lack of support of and parenting time with the child.
Date Signature of petitioning parent
1. I have joined in a petition with Name (type or print)
, whom I married
on Date
, requesting the adoption of the child named above and the termination of the
parental rights of the other parent name above.
2. I have custody of the child according to a court order. A copy of all court orders regarding custody are attached.
3. a. A support order has been entered and the other parent has failed to substantially comply with the order for a
period of two years or more before the petition for adoption was filed. Note: If a support order of $0.00 was entered, check 3b.
b. A support order has not been entered and the other parent, having the ability to support the child, has failed or
neglected to provide regular and substantial support for two years or more before the petition for adoption was filed.
4. The other parent has had the ability to visit, contact, and communicate with the child and has regularly and substantially
failed or neglected to do so for a period of two years or more before the petition for adoption was filed.
5. The last-known address of the other parent is
SUPPLEMENTAL PETITION
AFFIDAVIT
Supplemental Petition and Affidavit to Terminate Parental Rights (6/17) Page of File No.
6. a. The other parent is living at the above address.b. The other parent is not living at the above address, and I have taken the following steps to locate him/her:
Attorney signature Date
Attorney name (type or print) Bar no. Signature of petitioning parent
Address Address
City, state, zip Telephone no. City, state, zip Telephone no.
