Form Ad 925 Independent Adoption Placement Agreement (Indian Child)
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3STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
INDEPENDENT ADOPTION PLACEMENT AGREEMENT
(INDIAN CHILD)
This form MUST be signed after the Statement of Understanding (SOU) AD 927 AND Declaration of Mother (AD 880) forms have
been completed and signed. This Independent Adoption Placement Agreement WILL NOT be valid if it is signed prior to the SOU
AD 927 and AD 880.
PLACING PARENT SECTION
Note to placing parent: This form is a consent to adoption. Do not sign this form unless you want the prospective adoptive
parent(s) named below to adopt your child.
I/We, ____________________________________________________________________________, being the parent(s)
NAME OF PARENT(S)
I
I
of _____________________________________, (Gender:
M
F) born on ________________________________
DATE OF BIRTH
NAME OF CHILD
in _______________________________, place him/her with ________________________________________________
CITY AND STATE OF BIRTH
FULL NAME(S) OF PROSPECTIVE ADOPTIVE PARENT(S)
for the purpose of an independent adoption.
I/We understand that with the signing of this document, I/we will give up all my/our rights of custody, services and earnings of
this child.
I/We understand that this child is or may be covered under the Indian Child Welfare Act (ICWA).
If known, name of child’s tribe: ____________________________________________________
If known, tribal membership or enrollment number: _____________________________________
I/We understand that unless this child is confirmed as covered under ICWA, my/our right to revoke this consent is ONLY
DURING THE THIRTY (30) DAY PERIOD beginning on the date I/we sign this consent.
I/We understand that if this child is confirmed as covered under ICWA, I/we have the right to withdraw this Independent
Adoption Placement Agreement, at any time BEFORE THE FINAL DECREE of adoption has been entered in court.
I/We understand that if this child is later confirmed as covered under ICWA then the agency will notify me. I understand I
must keep the agency informed of my current address.
I/We have chosen the person(s) named above to be the parent(s) of my/our child based on my/our personal knowledge
about him/her/them.
I/We have been informed of the basic health and social history of the person(s) named above.
I/We understand that this child will not be considered to have been placed for adoption until the birth parent(s) placing the
child, prospective adoptive parent(s) and the Adoption Service Provider (ASP) have signed this Independent Adoption
Placement Agreement.
The person(s) named above have my/our permission to care for this child in his/her/their home.
The person(s) named above have my/our permission to make any provisions for medical and surgical care for this child,
including anesthesia, which may be deemed necessary or advisable by any licensed physician, for a period not to exceed
one year from the date this agreement is signed.
I/We was/were advised of my/our rights in the independent adoption process on _______________________. These
rights are summarized on the attached SOU (AD 927) which I/we have read and signed.
DATE
I/We have decided to place my/our child for adoption with the person(s) named above, and I/we am/are signing this freely
and willingly.
SIGNATURE OF PARENT
DATE SIGNED
SIGNATURE OF PARENT
DATE SIGNED
AD 925 (8/15) (INDEPENDENT ADOPTION PLACEMENT AGREEMENT)
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