Form Pca 350 - Petition And Order For Delayed Registration Of Foreign Birth Page 4
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4SIGNATURE(S)
This form should be signed by the adoptive parents with their current names. The adoptive parents should verify
information listed for the adoptive birth record.
____________________________________________
___________________________________________________________
Signature of Person Adopting
Signature of Husband or Wife (if married)
COURT CERTIFICATION
The Probate Court of ______________________________________________ County, Michigan
I hereby certify that this court has acknowledged the birth facts of the foreign born child, and the identified information about the adoptive parents dated
_____________________________.
Month
Day
Year
CASE NO. __________________________________________
__________________________________________
Judge
By _________________________________________
Probate Register
SEAL
OFFICE USE ONLY - DO NOT WRITE IN THIS AREA
PAYMENT - The fee for establishing a delayed registration of
foreign birth is $50.00 and includes one copy of the new record.
Additional copies of the new record are available for $16.00 each
when ordered at the same time. Normal processing time is 5-6
weeks. Payment must be made by check or money order
payable to the “State of Michigan.” The new birth record
will not be created until the recording fee has been paid.
Establish Delayed Registration of Foreign Birth
(Non-Refundable)
$ 50.00
Fee includes one (1) certified copy of the new record
________ Additional Certified Copies
$16.00 each
$
$
TOTAL ENCLOSED:
PENALTIES: Any person who willfully and knowingly makes false
application to change a Michigan birth record may be fined and/or
imprisoned. MCL 333.2894(1)(b) and (c).
DCH-0855 Rev 10-2013 MCL 333.2830(1) and 333.2891(5)(b).
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