Child's Last Name:

Child's First Name:

DHS Case No.:

MARE C No. - If child is not photolisted on MARE, please enter "N/A"

Date of Birth:
(mm/dd/yyyy)

Permanent Custody Date:
(mm/dd/yyyy)

Gender: Male Female

FAMILY INFORMATION:

Please fill in the appropriate section. If there are competing parties, please check all that apply and list all names

Foster Parent Adoption Planned

First and Last Name(s) of Foster Family:

-OR-

Relative Adoption Planned

First and Last Name(s) of Relative/Family:

Child living in home?  Yes No

Out of State Placement

Transfer Information - Please select either 'Yes' or 'No'

Is this a transfer case:
Yes
No

If this is a transfer case, please provide the name of the referring agency and the transfer date:

Referring Agency:   Date of Transfer:  (mm/dd/yyyy)

Agency Information

County of Commitment: (Please select one) Alcona Alger Allegan Alpena Antrim Arenac Baraga Barry Bay Benzie Berrien Branch Calhoun Cass Charlevoix Cheboygan Chippewa Clare Clinton Crawford Delta Dickinson Eaton Emmet Genesee Gladwin Gogebic Grand Traverse Gratiot Hillsdale Houghton Huron Ingham Ionia Iosco Iron Isabella Jackson Kalamazoo Kalkaska Kent Keweenaw Lake Lapeer Leelanau Lenawee Livingston Luce Mackinac Macomb Manistee Marquette Mason Mecosta Menominee Midland Missaukee Monroe Montcalm Montmorency Muskegon Newaygo Oakland Oceana Ogemaw Ontonagon Osceola Oscoda Otsego Ottawa Presque Isle Roscommon Saginaw Sanilac Schoolcraft Shiawassee St. Clair St. Joseph Tuscola Van Buren Washtenaw Wayne Wexford

Registering Agency:  

Adoption worker:  

Phone number:   format (xxx-xxx-xxxx)

Your email address:   (e.g., you@isp.com)

PLEASE NOTE:Agencies must still follow up with a PCA 320 in order to close this case. If at any time the family decides not to proceed with the adoption and no other approved family is available, the child must be registered in the MARE photolisting book by sending a standard (blue) MARE Child Registration Form and a clear, well-defined photo. If a new family has been identified, please send a new Hold form.