A17-3CC (01/2012) REPORT ON APPEALS AND REHEARINGS
STATE OF MICHIGAN
THIRD CIRCUIT COURT
WAYNE COUNTY
REPORT ON
APPEALS AND REHEARINGS
FILE NO.
IN THE MATTER OF
Adoptee
I represent that the records of
Court(s)
(State time, place and current status of each such appeal or request for rehearing)
Date Petitioner, department or child placing agency
Attorney, agency or-department
Address
City, state, zip Telephone no.
Space Below Line Reserved for Court Use