Fillable THIRD CIRCUIT COURT COVER SHEET Th e screening (Third Judicial Circuit of Michigan)

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THIRD CIRCUIT COURT COVER SHEET Th e screening (Third Judicial Circuit of Michigan)

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STATE OF MICHIGAN
THIRD CIRCUIT COURT
WAYNE COUNTY
AGENCY PETITION FOR ADOPTION PACKET
COVER SHEET
FILE NO.
Th
e screening process is intended to expedite the petition. Please advise the Court of any concerns or issues that could inhibit, hinder,
or delay the judicial finding that this adoption is in the adoptee’s best interest. Please use additional sheets of paper if necessary,
including to address any other issues of which the Court should be aware.
Child
Agency
Child’s D.O.B.
Worker Name:
Worker Phone:
Relationship of Child to Petitioner(s)
Worker Email:
Petitioner 1:
Agency Requests
Immediate Confirmation
Petitioner 2:
Supervision
Months in Home:
1. Has a request for an appeal ever been filed
by a birth parents?
No
Note: You must contact bo
th the Michigan Court of Appeals and
For termination that occurred in Wayne
the county where parental rights were terminated.
Yes by the Mother Fath
er
County, please verify by calling:
Court of Appeals Docket Number
(313) 833-1597
(Administration – County Clerk Appeals)
Status:
Pending
Closed
2. Is there a support order for any biological or
No
Adopted children of the adoptive petitioner(s)?
Yes
Is Support current?
Yes
No
Arrears: $
Account #:
If there is a current support order it must be submitted.
3. Are there any concerns shown on
No
the medical/health appraisals for any
Yes
List Concerns:
person living in the adoptive home?
4. Is there an active guardianship?
No
Yes
County:
File #:
5. Is this a licensed foster home?
No
(If so, attach most recent annual report)
Yes
Agency:
If this is a licensed foster home, the most recent annual report must be submitted.
6. Has/Have the petitioner(s) adopted before?
No
Yes
Date(s) of previous adoption(s):
Any prior adoptions set for court due to
No
concerns?
Yes
If there are prior adoptions, all previous home investigations must be submitted at the time of filing, from all involved agencies.
7. Do any adults in the adoptive home have
No
criminal history, or does any minor in the
Yes
Offender:
adoptive home have a juvenile record?
Date of Conviction:
Court of Conviction:
Active warrants must be resolved prior to filing the Petition for Adoption. A clearance from the court of conviction must be
obtained stating that all requirements have been met and that all fines have been paid.
8. Have any of the adults in the adoptive home
No
ever had protective service involvement?
Yes
Adult’s Name:
If a foster parent, have there been any
Investigation Date(s):
complaints/special investigations?
Total # of Complaints/Special Investigations:
Result(s):
If there are complaints, special evaluations, and/or corrective action plans, ALL must be submitted at the time of filing.
9. Has another family been denied the Consent
No
to Adoption by the MCI or a Court?
Yes
Name of Competing Party:
County of Termination:
I declare that the information has been examined by me and that its contents are true to the best of my information and knowledge.
Adoption Worker Date
Adoption Supervisor Date
MJC
1086 (6/14) AGENCY PETITION FOR ADOPTION PACKET COVER SHEET
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THIRD CIRCUIT COURT COVER SHEET Th e screening (Third Judicial Circuit of Michigan)

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Completed 29 July 2020

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