STATE OF MICHIGAN THIRD CIRCUIT COURT WAYNE COUNTY FILE NO. AGENCY PETITION FOR ADOPTION PACKET COVER SHEET Child Agency Child’s D.O.B. Age: Worker Name: Relationship of Child to Petitioner(s) Worker Phone Number: Worker Email: Petitioner 1 Agency is requesting: Petitioner 2 Immediate Confirmation Supervision Months in Adoptive Home The 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 a second sheet of paper if necessary) Has a request for an appeal ever been filed by a birth parents? No Yes (Administration – County Clerk) Appeals: (313) 833-1597) Mother Court of Appeals Docket Number Status: Is there a support order for any biological or Adopted children of the adoptive petitioner(s)? (Documentation Attached) Pending Closed No Yes Arrears: $ Are there any concerns shown on the medical/health appraisals for any person living in the adoptive home? No Is there an active guardianship? No Is this a licensed foster home? Father Yes Is Support current? Yes No , Account #: List Concerns: Yes Indicate County No Yes , File No Agency: If licensed, the most recent annual must be included in the packet. Has/Have the petitioner(s) adopted previously? No Yes Date(s) of previous adoption(s): Was/Were any of the previous adoptions Set for Court due to concerns? Yes No Please note – all previous home investigation(s) must be submitted at the time of filing, from all involved agencies. Do any of the adults in the adoptive home have criminal history? No Yes Does any minor, twelve years or older, in the adoptive home have a juvenile record? (For 3rd Circuit Court Record Checks please contact (313) 833-4633) Name of Offender: Date of Conviction: Court of Conviction: *Any known active warrants must be resolved prior to filing the Petition for Adoption. A clearance from the Court of Conviction must be obtained, prior to filing the adoption petition. The clearance must indicate that all requirements have been met and that all fines have been paid. Have any of the adults in the adoptive home ever had protective service involvement? If they are licensed foster parents, have they ever been involved in a complaint/special investigation? (Attach all reports) No Yes Adult’s Name: Date of Investigation: Result: Has another family been denied the Consent to Adoption by the MCI or a Court? No Yes Are there any other concerns the Court should be aware of? Name of Competing Party: County of Termination: No Yes List Concerns: 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 MJC 1086 (6/14) AGENCY PETITION FOR ADOPTION PACKET COVER SHEET Date