Form Ad 900 - Statement Of Understanding - Parent Who Gave Physical Custody Of The Indian Child To The Petitioner(S) Page 4
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9STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
RIGHTS UNDER THE INDIAN CHILD WELFARE ACT (ICWA)
My Child:
I
Has been confirmed as covered under the ICWA.
I
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 numbers 3 and 4 do not apply. Complete number 5 as well
.
_____ 3. 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: ____________________________________
_____ 4. 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 view 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 and my child will be returned to me.
_____ 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.
_____ e. If any agency or person goes to court to take away the parental rights of my child’s other
parent, my child’s tribe will be noticed and may participate in the proceedings.
_____ f. The adoption agency has to tell me if the adoption is set-aside or the adoptive
parent(s) agree(s) to the ending of his/her/their rights as parent(s) to my child. I
know that the notice will be given to me in writing. I understand I must keep the
adoption agency informed of my current address if I want to receive this notice.
AD 900 (7/17) PARENT WHO GAVE PHYSICAL CUSTODY (CUSTODIAL PARENT) OF THE INDIAN CHILD TO THE PETITIONER(S)
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