Form Ad 925 Independent Adoption Placement Agreement (Indian Child) Page 2
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3ADOPTION SERVICE PROVIDER SECTION
(advising and witnessing signature of birth parent(s))
I have advised the placing parent(s) as required by Family Code Section 8801.5.
I
The advisement occurred at least ten (10) days before the signing of this placement agreement or
I
Due to the attached exigent circumstances, the advisement occurred fewer than ten (10) days before the signing of
this placement agreement:
I, ________________________________________________, have witnessed the signing of this Independent Adoption
NAME OF WITNESS
Placement Agreement by _______________________________________________ on __________________________
DATE
PLACING PARENT(S)
in _________________________________.
CITY AND STATE WHERE SIGNED
I am:
I
A representative of ________________________________________, a California licensed private adoption agency.
NAME OF AGENCY
I
An individual California ASP.
I
A representative of ___________________________________________, an adoption agency licensed or otherwise
NAME OF AGENCY
approved under the laws of the state of __________________________________, the state where the Independent
Adoption Placement Agreement is being signed.
NAME OF STATE
I
An individual licensed or otherwise certified as a clinical social worker under the laws of _____________________,
the state where the Independent Adoption Placement Agreement is being signed.
NAME OF STATE
I
Independent counsel for the placing parent(s) serving as an ASP, pursuant to Family Code Section 8502(b) and
8801.5(e).
SIGNATURE OF INDIVIDUAL SERVING AS AN ASP
DATE
WHEN SIGNED OUT OF CALIFORNIA and the identification of the birth parent(s) is being questioned
then this form must also be signed in front of a Notary Public
The Notary Public must staple the Acknowledgement document to this form and sign and date below.
SIGNATURE OF NOTARY
DATE
ADOPTION AGENCY INVESTIGATING THIS ADOPTION
(to be completed by representative or ASP)
The adoption agency which will investigate this proposed independent adoption is:
NAME OF CDSS ADOPTION OFFICE/DELEGATED COUNTY ADOPTION AGENCY
ADDRESS
TELEPHONE NUMBER
CERTIFICATE OF THE COURT
The parent of this child to whom the ICWA does apply or may apply, and the ASP, whose signatures are affixed above,
appeared in my presence on ________________. This voluntary adoption placement agreement has been given at least
DATE
ten (10) days after the birth of the child. The terms and consequences of the voluntary signing of this adoption placement
agreement have been fully explained in English, or translated in a language understood by the parent, including the right
to withdraw the adoption placement agreement prior to the final decree of adoption if the child is confirmed to be covered
under ICWA.
SIGNATURE OF SUPERIOR COURT JUDGE
DATE
NAME OF SUPERIOR COURT JUDGE
NAME OF COURT JURISDICTION
AD 925 (8/15) (INDEPENDENT ADOPTION PLACEMENT AGREEMENT)
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