STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATEMENT OF UNDERSTANDING
Parent Who Did Not Give Physical Custody of the
INDIAN Child to the Petitioner(s)
_____ 1. I have carefully considered the reasons for consenting to the adoption of
______________________________________ by ______________________________________.
NAME(S) OF THE PETITIONER(S)
NAME OF CHILD
RIGHTS UNDER THE INDIAN CHILD WELFARE ACT (ICWA)
My Child:
Has been confirmed as covered under the ICWA.
Has not been confirmed as covered under the ICWA, but may be covered. Therefore, I am being
advised of these rights. I understand that until my child is confirmed as covered under the ICWA, the
rights described below in number 2 and 3 do not apply. Complete number 4 as well.
_____ 2. I understand because my child is or may be an Indian child, the requirements of the ICWA will
apply to the signing of my consent to adoption form and the adoption of my child.
If Known, Name of Child’s Tribe:_____________________________________________________
If Known, Tribal Membership or Enrollment Number:_____________________________________
_____ 3. I understand that in a case of a child who has been confirmed as covered under the ICWA the
following rights apply:
_____ a. According to the ICWA, the best place for my child to live if he/she cannot be with me
would be with a member of his/her extended family. If that is not possible, the next
choice would be with other members of my child’s tribe. If placement with the tribe is
not possible, the third choice would be with another Indian family.
If I do not wish to follow any of these placement choices, I must tell the court so that the
court can consider my views in the final decision on where my child will be placed.
_____ b. If I should change my mind about the adoption after signing the consent to adoption
form, I may withdraw the consent to adoption form before the adoption is granted by the
court. However, the only way I may regain custody of the child is if I request the right to
physical custody of the child in court. I probably will need a lawyer to help me do this.
_____ c. I will be told immediately if my child’s other parent asks to take back his/her consent to
adoption and of any court proceedings because he/she is asking to take back the
consent to adoption. I understand I must keep the adoption agency informed of my
current address if I want to receive this notice.
_____ d. The child’s Indian tribe has a right to be noticed and participate in the adoption
proceedings.
PAGE 2 OF 7
AD 900A (6/17) PARENT WHO DID NOT GIVE PHYSICAL CUSTODY (NON-CUSTODIAL) OF THE INDIAN CHILD TO THE PETITIONER(S)