Form Ad 900 - Statement Of Understanding - Parent Who Gave Physical Custody Of The Indian Child To The Petitioner(S) Page 9

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
SECTION C - CERTIFICATE OF THE COURT
Complete if signed in or out of California
The parent of this child to whom the ICWA does apply or may apply, and the authorized agency official,
whose signatures are affixed above, appeared in my presence on_____________. This Statement of
Understanding has been given at least ten (10) days after the birth of the child. The terms and
consequences of the voluntary signing of the consent to adoption and this Statement of Understanding
have been fully explained in English, or translated in a language understood by the parent, including the
right to withdraw the consent prior to the final decree of adoption if the child is confirmed to be covered
under the ICWA.
AD 900 (7/17) PARENT WHO GAVE PHYSICAL CUSTODY (CUSTODIAL PARENT) OF THE INDIAN CHILD TO THE PETITIONER(S)
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