Form Ad 927 - Statement Of Understanding - Parent Who Places The Indian Child With The Prospective Adoptive Parent(S) Page 8

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
SECTION B — Certificate of the Court
Complete if signed in or out of California
The parent of this child to whom the ICWA does apply or may apply, and the Adoption Service Provider,
whose signatures are affixed above, appeared in my presence on ________________. This Statement of
Understanding has been given at least ten (10) days after the birth of the child. The terms and
consequences of the voluntary signing of the Adoption Placement Agreement and this Statement of
Understanding 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 the ICWA.
SIGNATURE OF SUPERIOR COURT JUDGE
DATE
NAME OF SUPERIOR COURT JUDGE
NAME OF COURT JURISDICTION
AD 927 (7/17) PARENT OF INDIAN CHILD WHO PLACES THE CHILD WITH THE PROSPECTIVE ADOPTIVE PARENT(S)
PAGE 8 OF 8

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