Statement Of Services Performed By Agency Or Family Independence Agency {PCA 345}

PCA 345 - STATEMENT OF SERVICES PERFORMED BY AGENCY/DEPARTMENT OF HEALTH AND HUMAN SERVICES. This form is used in Michigan by a child-placing agency or the Michigan Department of Health and Human Services to itemize and disclose all services provided and any fees or compensation received for the adoption of a child. If no fees or compensation were received, this is noted in the form. It includes the dates of services, details of each service, and any associated fees or payments. A representative from the agency or department completes the form under penalty of perjury, and it must be attached to the Petitioner’s Verified Accounting form as part of the adoption paperwork. Approved, SCAO. MCL 710.54(7), MCL 710.54(8). www.FormsWorkflow.com