Skip to content
LitigationForms
PCA 345

Statement of Services Performed by Agency/Department of Health and Human Services

Michigan · Michigan State Court Administrative Office · Effective August 1, 2024

This form is a statement used to list any services, fees, or other value that the child-placing agency or the Michigan Department of Health and Human Services received for the adoption of a child. It requires the representative to declare that the listed information is true under penalty of perjury.

The court describes it as: Court rule / statute: MCL 710.54(7), MCL 710.54(8)

Open the official PDFfrom Michigan State Court Administrative Office

Where this fits in a case

General & info

Information / general use — not tied to one step of a case

This form is used in the context of an adoption case to document the services provided and any associated payments or values related to the adoption.

Prepared by the court or clerk.

Common questions

Who fills out this form?
A representative of the child-placing agency or the Michigan Department of Health and Human Services fills out this form. The representative must have the authority to make the statement.
What does the form track?
It tracks services performed, along with any fee, compensation, or other thing of value received by the agency or the Department of Health and Human Services for the adoption.
What must be done if no money was paid?
If no fee, compensation, or other thing of value was paid or agreed to be paid, the form instructs the user to write “NONE” in the fee column.

Revision history

No changes recorded since we started tracking this form on October 9, 2026. The current version took effect August 1, 2024.

Related forms

  • PCA 347

    Petitioner's Verified Accounting

    This form is a detailed list of all money spent or promised to be spent for an adoption. It asks the court to approve these payments and expenses.

    Fillable PDF
  • CCFD 23

    Status Report / Notice (Collaborative Law Process)

    This form is a Status Report and Notice used in the collaborative law process. It asks the parties to report the current status of the process by checking if it is ongoing, concluded, or terminated, and requires signatures from the parties and their attorneys.

    MandatoryFillable PDF
  • FOC 101

    Advice of Rights Regarding Use of Friend of the Court Services

    This form explains the rights of people regarding using the Friend of the Court Services. It details what services are available and outlines the process and conditions for choosing to refuse these services.

    MandatoryFillable PDF
  • FOC 103

    Notice of Closure of Friend of the Court Case

    This form is a notice that tells people that the Friend of the Court's involvement in a case is ending. It asks the recipient to check a box that explains what action should be taken regarding future income management.

    Fillable PDF
  • FOC 108

    Change in Personal Information

    This form is used to tell the court about changes to personal details, such as your address, name, or job. It asks for updated information for yourself or minor children you have physical custody of.

    Fillable PDF
  • FOC 118

    Prisoner Information Addendum

    This form is an addendum used to collect detailed personal, financial, and custody information from a person who is currently in prison. It asks for details about income, assets, and the location of any child custodians.

    Fillable PDF
  • FOC 1a

    Friend of the Court Grievance

    This form is used to file a complaint, called a grievance, about the actions of an employee or the office operations of the friend of the court. It asks the friend of the court or chief judge to investigate and respond to the complaint.

    Fillable PDF
  • FOC 22

    Employer's Disclosure of Health Insurance and/or Income Information

    This form asks an employer to provide detailed information about an employee's income, health insurance, and other financial details. It is used to gather specific financial records for the court.

    Fillable PDF