Form Ad 900 - Statement Of Understanding - Parent Who Gave Physical Custody Of The Indian Child To The Petitioner(S) Page 2

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATEMENT OF UNDERSTANDING
Parent Who Gave Physical Custody of the INDIAN
Child to the Petitioner(s)
_____ 1. I want my child, ________________________________________________________, permanently
NAME OF CHILD
placed with ____________________________________________________________ for adoption.
NAME(S) OF THE PETITIONER(S)
_____ 2. I have chosen the petitioner(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 PETITIONER(S)
First Petitioner:
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:
_______________________________________________________________________________
_______________________________________________________________________________
AD 900 (7/17) PARENT WHO GAVE PHYSICAL CUSTODY (CUSTODIAL PARENT) OF THE INDIAN CHILD TO THE PETITIONER(S)

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