Form PCA 340 Statement of Identifying Information - Michigan

Form PCA340 is a Michigan Circuit Court form also known as the "Statement Of Identifying Information". The latest edition of the form was released in June 1, 2017 and is available for digital filing.

Download a PDF version of the Form PCA340 down below or find it on Michigan Circuit Court Forms website.

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Approved, SCAO
JIS CODE:SII
STATE OF MICHIGAN
FILE NO.
JUDICIAL CIRCUIT - FAMILY DIVISION
STATEMENT OF
COUNTY
IDENTIFYING INFORMATION
In the matter of adoptee
DOB:
Full name of child
1. I am assisting the
parent
guardian in this adoption.
2. The parties have elected not to exchange identifying information.
3. The surname and current place of residence of the adoptee are
Name
.
Address
4. The name and address of each parent are:
Name and address of mother
Name and address of father
5. The name and address of the court-appointed guardian of the adoptee are
Name
.
Address
I declare that this statement has been examined by me and that its contents are true to the best of my information, knowledge,
and belief.
Date
Signature of attorney or agency representative
Name of attorney or agency representative (print)
Bar no.
Name of firm or child-placing agency
Address
City, state, zip
Telephone no.
.
Do not write below this line - For court use only
STATEMENT OF IDENTIFYING INFORMATION
PCA 340 (6/17)
MCL 710.24(7)
Approved, SCAO
JIS CODE:SII
STATE OF MICHIGAN
FILE NO.
JUDICIAL CIRCUIT - FAMILY DIVISION
STATEMENT OF
COUNTY
IDENTIFYING INFORMATION
In the matter of adoptee
DOB:
Full name of child
1. I am assisting the
parent
guardian in this adoption.
2. The parties have elected not to exchange identifying information.
3. The surname and current place of residence of the adoptee are
Name
.
Address
4. The name and address of each parent are:
Name and address of mother
Name and address of father
5. The name and address of the court-appointed guardian of the adoptee are
Name
.
Address
I declare that this statement has been examined by me and that its contents are true to the best of my information, knowledge,
and belief.
Date
Signature of attorney or agency representative
Name of attorney or agency representative (print)
Bar no.
Name of firm or child-placing agency
Address
City, state, zip
Telephone no.
.
Do not write below this line - For court use only
STATEMENT OF IDENTIFYING INFORMATION
PCA 340 (6/17)
MCL 710.24(7)

Download Form PCA 340 Statement of Identifying Information - Michigan

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