Parental Consent To [foster Care, Adoption, Termination Of Parental Rights] Of An Indian Child

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PARENTAL CONSENT TO
[FOSTER CARE, ADOPTION, TERMINATION OF PARENTAL RIGHTS]
OF AN INDIAN CHILD
In the Matter of the Petition of:
_____________________________________________________________________
Petitioner
County of:_____________________________ State of:________________________
I, __________________________________________________________________
Name of Parent
being the
: Birth mother___ Biological Father____ Presumed Father___ Other Legal Parent___
(choose one)
Of _____________________________________________ (Gender: F__ M__) born on________________
Name of Child
Child’s Birth Date
In ____________________________________________________________________________________
Child’s Place of Birth
give my consent to the [foster care, adoption, termination of parental rights] of said child
[If adoption, by ________________________________________________________]
Name of Petitioner(s)
Under the following conditions__________________________________________________________
__________________________________________________________________________________
State “None” if there are no conditions to this consent.
I understand that I may revoke this consent ONLY PRIOR TO ENTRY OF A FINAL ORDER. I further understand
that with the signing of the order of adoption or termination of parental rights by the court, I give up all rights of
custody, services, and earnings of said child and I may not reclaim said child.
___________________________________
__________________
Signature of Parent
Date
____________________________________________________________________________________
Address of Parent
Additional Information
Name of the Indian child’s Tribe:___________________________________________________________
Tribal enrollment number for the parent (if known): _____________________________________________
Tribal enrollment number for the Indian child (if known): _________________________________________
Name and address of the person or entity, if any, who arranged the placement: ______________________
Name and address of the prospective foster parents (if known):___________________________________
I certify that the terms and consequences of the consent were explained on the record in detail in English (or the
language of the parent or Indian custodian, if English is not the primary language) and were fully understood by the
parent or Indian custodian.
___________________________________
__________________
Signature of Court Official
Date

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Related Categories

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