Form Ad 927 - Statement Of Understanding - Parent Who Places The Indian Child With The Prospective Adoptive Parent(S) Page 5
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8STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
_____ k. I may ask the court to stop any action ending my rights as a parent if the action did not
follow the ICWA.
_____ l. I must sign the adoption placement agreement form before a Judge of the Superior Court in
California, or if signed outside the State of California, a Judge of an equivalent state court.
TO BE COMPLETED BY THE BIRTH PARENT WHOSE CHILD HAS NOT BEEN CONFIRMED
AS COVERED UNDER THE ICWA
_____ 5. BIRTH PARENT WILL ONLY INITIAL THE BELOW STATEMENTS IF the child has not been
confirmed as covered under the ICWA.
_____ a. I understand that if my child is later determined NOT to be subject to the ICWA,
then the below rights described in (1) — (3) will apply to my child and the above
rights described in numbers 3 and 4 will not apply to my child.
_____ (1) I understand the adoption placement agreement will automatically become an
irrevocable consent to adoption when the 30-day period has ended, or when I
sign a Waiver of the Right to Revoke Consent (AD 929), whichever occurs first.
The first day of the 30-day period is the day the adoption placement agreement
is signed.
_____ (2) If I change my mind after I sign the adoption placement agreement, I must sign
and deliver to the California Department of Social Services or to the delegated
county adoption agency, whichever is investigating the proposed adoption, a
written statement revoking the adoption placement agreement and requesting
that the child be returned to me. I may not revoke the adoption placement
agreement after the 30-day period has ended or after I sign a Waiver of the
Right to Revoke Consent (AD 929), whichever occurs first. The first day of the
30-day period is the day the adoption placement agreement is signed.
_____ (3) After the adoption placement agreement becomes irrevocable, I may regain
custody of the child only if the prospective adoptive parent(s) agree(s) to
withdraw his/her/their petition for adoption, or if the court denies the adoption
petition.
_____ b. I understand that if this child is later confirmed as covered under the ICWA, then the
investigating agency will notify me and the rights described in number 3 and 4,
including the right to withdraw the consent before the adoption is granted by the
court, will apply. I understand I must keep the agency informed of my current
address.
RIGHTS IN EVERY CASE
_____ 6. I understand if I do not wish to place my child for adoption with the prospective adoptive parent(s), I
should not sign this form and the adoption placement agreement.
_____ 7. I understand I have the right to look for a lawyer to help me in the independent adoption process and
that the prospective adoptive parent(s) may be required to pay the cost, up to $500 unless the
prospective adoptive parent(s) and I agree to a higher amount, of such legal counsel.
PAGE 5 OF 8
AD 927 (7/17) PARENT OF INDIAN CHILD WHO PLACES THE CHILD WITH THE PROSPECTIVE ADOPTIVE PARENT(S)
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