Notice Of Petition And Petition To Transfer Case To Tribal Jurisdiction Page 3
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3ICWA-050
CHILD'S NAME:
CASE NUMBER:
b.
Mail. I deposited a copy of form ICWA-050 and all attachments in the United States mail, in a sealed envelope with
postage fully prepaid, addressed as follows:
(2) Name of
parent (if self-represented)
(1) Name of child's attorney (if applicable) served:
or
parent's attorney (if applicable) served:
(a) Address:
(a) Address:
(b) Date of deposit:
(b) Date of deposit:
(c) Place of deposit:
(c) Place of deposit:
(3) Name of Appointed Special
(4) Name of
social worker (dependency only)
Advocate (if applicable) served:
or
probation officer (delinquency only)
(a) Address:
served:
(a) Address:
(b) Date of deposit:
(c) Place of deposit:
(b) Date of deposit:
(c) Place of deposit:
(5) Name of
child's caregiver
or
Indian custodian served:
(6) Attorney for child welfare services agency
(dependency only) served:
(a) Address:
(a) Address:
(b) Date of deposit:
(b) Date of deposit:
(c) Place of deposit:
(c) Place of deposit:
(7) Name of
parent (if self-represented)
or
parent's attorney (if applicable) served:
(8) District Attorney
(delinquency only) served:
(a) Address:
(a) Address:
(b) Date of deposit:
(b) Date of deposit:
(c) Place of deposit:
(c) Place of deposit:
c.
Attachment. If there are additional persons to serve, attach a separate piece of paper to form ICWA-050, write the
child's name and case number on the top, and list additional persons' names, addresses, dates of delivery or deposit,
times of delivery or deposit, and whether service was made personally or by mail.
I declare under penalty of perjury under the laws of the State of California that the foregoing and all attachments are true and correct.
Date:
(TYPE OR PRINT NAME)
(SIGNATURE OF PERSON WHO SERVED NOTICE)
Page 3 of 3
ICWA-050 [New January 1, 2008]
NOTICE OF PETITION AND PETITION TO TRANSFER CASE
INVOLVING AN INDIAN CHILD TO TRIBAL JURISDICTION
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