Form Ad 927 - Statement Of Understanding - Parent Who Places The Indian Child With The Prospective Adoptive Parent(S) Page 2

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CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
STATEMENT OF UNDERSTANDING
Parent Who Places the INDIAN Child With
the Prospective Adoptive Parent(s)
_____ 1. I want to place my child,__________________________________________________________,
NAME OF CHILD
permanently with________________________________________________for adoption.
NAME(S) OF THE PROSPECTIVE ADOPTIVE PARENT(S)
_____ 2. I have chosen the prospective adoptive parent(s) to be the parent(s) for my child based on my
personal knowledge of at least the following information about him/her/them:
PERSONAL KNOWLEDGE OF PROSPECTIVE ADOPTIVE PARENT(S)
First Prospective Adoptive Parent:
Full Legal Name: ___________________________________________________________________
Age: _____ Religion: ___________________ Race and Ethnicity: _____________________________
Number of previous marriages: _____ Employment: _______________________________________
Health conditions restricting normal daily activities or reducing normal life expectancy:
_________________________________________________________________________________
_________________________________________________________________________________
Children who do not live in the home; child support obligation for these children; and any failure to
meet child support obligations:
_________________________________________________________________________________
_________________________________________________________________________________
Any history of arrest and convictions for any crimes other than minor traffic violations:
_________________________________________________________________________________
_________________________________________________________________________________
Any removals of children from care due to child abuse or neglect:
_________________________________________________________________________________
_________________________________________________________________________________
Second Prospective Adoptive Parent:
Full Legal Name:____________________________________________________________________
Age: _____ Religion: ___________________ Race and Ethnicity: _____________________________
Number of previous marriages: _____ Employment: _______________________________________
Health conditions restricting normal daily activities or reducing normal life expectancy:
_________________________________________________________________________________
_________________________________________________________________________________
AD 927 (7/17) PARENT OF INDIAN CHILD WHO PLACES THE CHILD WITH THE PROSPECTIVE ADOPTIVE PARENT(S)
PAGE 2 OF 8

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