Out-Of-Court Consent To Direct Placement Adoption By Parent
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3STATE OF MICHIGAN
OUT-OF-COURT CONSENT TO DIRECT
FILE NO.
COUNTY OF
PLACEMENT ADOPTION BY PARENT
NOTICE: THIS CONSENT CANNOT BE SIGNED BEFORE THE EXPIRATION OF A 72 HOUR WAITING
PERIOD FOLLOWING THE BIRTH OF THE ADOPTEE. FOR USE IN NON-INDIAN ADOPTIONS ONLY.
In the matter of ________________________________________________________________, adoptee
Full name of child
□
1. I, _____________________________, am the
mother (Date of Birth
)
□
father (Date of Birth
)
of the child named above who was born, ____________ at _________am/pm in ____________________
Date
Time
City
___________________________________________________________________________________.
County
State
[Instructions: Initial each line only after reading and fully understanding each paragraph]
2. ______ I have had my legal rights as a parent fully explained to me and I understand that I do not have to sign
this out-of-court consent to adoption. I understand my parental rights and that if I do sign this out-of-
court consent, I voluntarily give up permanently all my parental rights to my child for adoptive
placement with
□
a. The petitioner(s), who have or intend to file a petition for the adoption of the adoptee
and whose name(s) is/are unknown to me because identifying information is not being
exchanged.
□
b. ________________________________, who have filed or intend to file a petition for
Name(s) of petitioner(s)
the adoption of my child.
3. ______ I have read or have had read to me each of my rights as a parent described in section 44(8)(c) of
chapter X of the probate code of 1939, 1939 PA 288, MCL 710.44, and I understand these rights.
4. ______ This out-of-court consent does not involve an Indian child as defined in MCR 3.002(12).
5. ______ I have been advised and understand that by signing this out-of-court consent, I am giving up all of my
parental rights and authorizing the court to permanently terminate all of my parental rights (unless the
court allows me to revoke my out-of-court consent), including but not limited to:
a. The right to have or to seek care and custody of the child
b. The right to have or to seek parenting time with the child.
c. The right to inherit from the child or have the child inherit from the parent.
d. The right to services and earnings of the child.
e. The right to determine the child’s schooling, religious training, and parenting practices.
6. ______ I am signing the out-of-court consent as a free and voluntary act on my part and I have been advised
that I cannot be forced to sign the out-of-court consent for any reason.
7. ______ I have not been given or promised any money or other thing of value in exchange for signing the out-
of-court consent.
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