Form Ad 900a - Statement Of Understanding - Parent Who Did Not Give Physical Custody Of The Indian Child To The Petitioner(S) Page 4
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7STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
TO BE COMPLETED BY THE BIRTH PARENT WHOSE CHILD HAS NOT BEEN CONFIRMED
AS COVERED UNDER THE ICWA
____ 4. 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 2 and 3 will not apply to my child.
_____ (1) I understand the consent to adoption form 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 consent to adoption
form is signed.
_____ (2) If I change my mind after I sign the consent to adoption form, 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 consent. I may not revoke the consent 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 consent to adoption form is signed.
_____ (3) After the consent to adoption form becomes irrevocable, I may attempt to gain
custody of the child only if the petitioner(s) agree(s) to withdraw his/her/their
petition for adoption, or if the court denies the adoption petition. 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.
_____ 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 numbers 2 and 3, 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
_____ 5. I understand if I do not wish to have my child adopted by the petitioner(s), I should not sign this
form and the consent to adoption form.
_____ 6. I understand if I do not consent to the adoption, I may sign a Refusal to Give Consent to Adoption
form (AD 20) or write a letter to the adoption agency and the adoption agency will report to the
court that I do not want my child to be adopted by the petitioner(s).
_____ 7. I understand if I do not sign the consent to adoption form, I may request the right to physical
custody of the child in court. I probably will need a lawyer to help me do this.
AD 900A (6/17) PARENT WHO DID NOT GIVE PHYSICAL CUSTODY (NON-CUSTODIAL) OF THE INDIAN CHILD TO THE PETITIONER(S)
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