Form Soc 820 - Notice Of Involuntary Child Custody Proceedings For An Indian Child (Juvenile Court) Page 3

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CASE NAME:
CASE NUMBER:
INFORMATION ON CHILD WHO IS THE SUBJECT OF AN INVOLUNTARY CUSTODY PROCEEDING
(Indicate if any of the information requested below is unknown or nonapplicable.)
Maternal
Paternal
Maternal
Paternal
Grandmother
Grandfather
Grandmother
Grandfather
NAME (including maiden, married, and former or aliases):
NAME (including maiden, married, and former or aliases):
ADDRESS (current and former)
ADDRESS (current and former)
BIRTHDATE AND PLACE:
BIRTHDATE AND PLACE:
TRIBE, BAND, AND LOCATION:
TRIBE, BAND, AND LOCATION:
IF AVAILABLE, ENROLLMENT NUMBER OR BIA/TRIBAL AGENCY NAME:
IF AVAILABLE, ENROLLMENT NUMBER OR BIA/TRIBAL AGENCY NAME:
IF DECEASED, DATE AND PLACE OF DEATH:
IF DECEASED, DATE AND PLACE OF DEATH:
ADDITIONAL INFORMATION:
ADDITIONAL INFORMATION:
Maternal
Paternal
Maternal
Paternal
Grandmother
Grandfather
Grandmother
Grandfather
NAME (including maiden, married, and former or aliases):
NAME (including maiden, married, and former or aliases):
ADDRESS (current and former)
ADDRESS (current and former)
BIRTHDATE AND PLACE:
BIRTHDATE AND PLACE:
TRIBE, BAND, AND LOCATION:
TRIBE, BAND, AND LOCATION:
IF AVAILABLE, ENROLLMENT NUMBER OR BIA/TRIBAL AGENCY NAME:
IF AVAILABLE, ENROLLMENT NUMBER OR BIA/TRIBAL AGENCY NAME:
IF DECEASED, DATE AND PLACE OF DEATH:
IF DECEASED, DATE AND PLACE OF DEATH:
ADDITIONAL INFORMATION:
ADDITIONAL INFORMATION:
NOTICE OF INVOLUNTARY CHILD CUSTODY PROCEEDINGS FOR AN INDIAN CHILD
25 U.S.C. § 1901 et. seq.
(Juvenile Court)
SOC 820 (10/04)
PAGE 3 OF 6

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