Form Ad 900 - Statement Of Understanding - Parent Who Gave Physical Custody Of The Indian Child To The Petitioner(S) Page 3

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Second 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:
________________________________________________________________________________
______________________________________________________________________________
Family:
Length of current marriage/relationship:
________________________________________________________________________________
General residence or location, if requested, specific address:
______________________________________________________________________________
_____________________________________________________________________________
Other children and adults residing in the home of the petitioner(s):
______________________________________________________________________________
_____________________________________________________________________________
______________________________________________________________________________
AD 900 (7/17) PARENT WHO GAVE PHYSICAL CUSTODY (CUSTODIAL PARENT) OF THE INDIAN CHILD TO THE PETITIONER(S)

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