Free ICWA-030.v17 101007 mc.ofm - California

CONFIDENTIAL
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address):

ICWA-030
FOR COURT USE ONLY

TELEPHONE NO.: E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name):

FAX NO. (Optional):

SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: TELEPHONE NO.:

CASE NAME:
CASE NUMBER:

NOTICE OF CHILD CUSTODY PROCEEDING FOR INDIAN CHILD (check all that apply):
Dependency Delinquency JUVENILE ADOPTION CUSTODY (Fam. Code, § 3041) CONSERVATORSHIP* DECLARATION OF FREEDOM FROM CONTROL OF PARENT GUARDIANSHIP TERMINATION OF PARENTAL RIGHTS VOLUNTARY RELINQUISHMENT OF CHILD BY PARENT NOTICE TO (check all that apply): Parents or Legal Guardians Secretary of the Interior Tribes Indian Custodians

HEARING DATE:

DEPT.:

Sacramento Area Director, BIA

1. NOTICE is given that based on the petition, a copy of which is attached to this notice, a child custody proceeding under the Indian Child Welfare Act (25 U.S.C. § 1901 et seq.) has been initiated for the following child (a separate notice must be filed for each child): Name Date of Birth Place of Birth

2.

HEARING INFORMATION a. Date: Time: Type of hearing: b. Address and telephone number of court same as noted above is (specify): Dept.: Room:

3. The child is or may be eligible for membership in the following Indian tribes (list each):

*Use this form in a conservatorship only if the proposed conservatee is a formerly married minor.
Form Adopted for Mandatory Use Judicial Council of California ICWA-030 [New January 1, 2008]

Page 1 of 10 25 U.S.C. § 1901 et seq.; Welfare & Institutions Code, §§ 224.2, 224.3; Probate Code, §§ 1449, 1459.5; 1460.2; Cal. Rules of Court, rules 5.480­5.487 and 7.1015 www.courtinfo.ca.gov American LegalNet, Inc. www.FormsWorkflow.com

NOTICE OF CHILD CUSTODY PROCEEDING FOR INDIAN CHILD
(Indian Child Welfare Act)

ICWA-030
CASE NAME:
CASE NUMBER:

4. Under the Indian Child Welfare Act (ICWA) and California law: a. The child's parents, Indian custodian, and the child's tribe have the right to be present at all hearings. b. The child's Indian custodian and the child's tribe have the right to intervene in the proceedings when ICWA applies. c. The child's parent, Indian custodian, or tribe may petition the court to transfer the case to the tribal court of the Indian child's tribe. The child's parent or tribe also have the right to refuse to have the case transferred to the tribal court. d. With the limited exceptions of the detention hearing in juvenile cases and the jurisdiction and disposition hearings in delinquency cases as identified in rule 5.482, the court will give up to 20 days from the time of the scheduled hearing if the child's parent, Indian custodian, or tribe request such time to prepare for the hearing. e. The proceedings could lead to the removal of the child from the custody of the parent or Indian custodian and possible adoption of the child. f. If the child's parents or Indian custodian have a right to be represented by a lawyer and if they cannot afford to hire one, a lawyer will be appointed for them. g. The information contained in this notice and all attachments is confidential. Any tribal representative or agent or any other person or entity receiving this information must maintain the confidentiality of this information and not reveal it to anyone who does not need the information in order to exercise the tribe's rights under the Indian Child Welfare Act (25 U.S.C. § 1901 et seq.). h. An Indian custodian is any person who has legal custody of the child under tribal law or custom or state law, or to whom temporary physical custody, care, and control of the child has been transferred by a parent. 5. INFORMATION ON THE CHILD NAMED IN 1 a. The child's birth certificate is attached b. A copy of the tribal registration card of the child

unavailable the parent is attached.

c. Biological relative information is listed below. (Indicate if any of the information requested below is unknown or does not apply. Do not use the abbreviation "N/A".) (Required by Fam. Code, § 180; Prob. Code, § 1460.2; and Welf. & Inst. Code, § 224.2.)

Biological Mother
Name (include maiden, married, and former names or aliases):

Biological Father
Name (include former names or aliases):

Current address:

Current address:

Former address:

Former address:

Birth date and place:

Birth date and place:

Tribe or band, and location:

Tribe or band, and location:

Tribal membership or enrollment number, if known: If deceased, date and place of death:

Tribal membership or enrollment number, if known: If deceased, date and place of death:

Additional information:

Additional information:

ICWA-030 [New January 1, 2008]

NOTICE OF CHILD CUSTODY PROCEEDING FOR INDIAN CHILD
(Indian Child Welfare Act)

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ICWA-030
CASE NAME:
CASE NUMBER:

5. c. INFORMATION ON THE CHILD NAMED IN 1 (Indicate if any of the information requested below is unknown or does not apply; do not use the abbreviation "N/A".)

Mother's Biological Mother (Child's Maternal Grandmother)
Name (include maiden, married, and former names or aliases):

Father's Biological Mother (Child's Paternal Grandmother)
Name (include maiden, married, and former names or aliases):

Current address:

Current address:

Former address:

Former address:

Birth date and place:

Birth date and place:

Tribe or band, and location:

Tribe or band, and location:

Tribal membership or enrollment number, if known:

Tribal membership or enrollment number, if known:

If deceased, date and place of death:

If deceased, date and place of death:

Mother's Biological Father (Child's Maternal Grandfather)
Name (include former names or aliases):

Father's Biological Father (Child's Paternal Grandfather)
Name (include former names or aliases):

Current address:

Current address:

Former address:

Former address:

Birth date and place:

Birth date and place:

Tribe or band, and location:

Tribe or band, and location:

Tribal membership or enrollment number, if known:

Tribal membership or enrollment number, if known:

If deceased, date and place of death:

If deceased, date and place of death:

ICWA-030 [New January 1, 2008]

NOTICE OF CHILD CUSTODY PROCEEDING FOR INDIAN CHILD
(Indian Child Welfare Act)

Page 3 of 10

ICWA-030
CASE NAME:
CASE NUMBER:

5. d. INFORMATION ON THE CHILD NAMED IN 1 (Indicate if any of the information requested below is unknown or does not apply; do not use the abbreviation "N/A".)

Mother's Biological Grandmother (Child's Maternal Great-grandmother)
Name (include maiden, married, and former names or aliases):

Mother's Biological Grandmother (Child's Maternal Great-grandmother)
Name (include maiden, married, and former names or aliases):

Current address:

Current address:

Former address:

Former address:

Birth date and place:

Birth date and place:

Tribe or band, and location:

Tribe or band, and location:

Tribal membership or enrollment number, if known:

Tribal membership or enrollment number, if known:

If deceased, date and place of death:

If deceased, date and place of death:

Mother's Biological Grandfather (Child's Maternal Great-grandfather)
Name (include former names or aliases):

Mother's Biological Grandfather (Child's Maternal Great-grandfather)
Name (include former names or aliases):

Current address:

Current address:

Former address:

Former address:

Birth date and place:

Birth date and place:

Tribe or band, and location:

Tribe or band, and location:

Tribal membership or enrollment number, if known:

Tribal membership or enrollment number, if known:

If deceased, date and place of death:

If deceased, date and place of death:

ICWA-030 [New January 1, 2008]

NOTICE OF CHILD CUSTODY PROCEEDING FOR INDIAN CHILD (Indian Child Welfare Act)

Page 4 of 10

ICWA-030
CASE NAME:
CASE NUMBER:

5. e. INFORMATION ON THE CHILD NAMED IN 1 (Indicate if any of the information requested below is unknown or does not apply; do not use the abbreviation "N/A".)

Father's Biological Grandmother (Child's Paternal Great-grandmother)
Name (include maiden, married, and former names or aliases):

Father's Biological Grandmother (Child's Paternal Great-grandmother)
Name (include maiden, married, and former names or aliases):

Current address:

Current address:

Former address:

Former address:

Birth date and place:

Birth date and place:

Tribe or band, and location:

Tribe or band, and location:

Tribal membership or enrollment number, if known:

Tribal membership or enrollment number, if known:

If deceased, date and place of death:

If deceased, date and place of death:

Father's Biological Grandfather (Child's Paternal Great-grandfather)
Name (include former names or aliases):

Father's Biological Grandfather (Child's Paternal Great-grandfather)
Name (include former names or aliases):

Current address:

Current address:

Former address:

Former address:

Birth date and place:

Birth date and place:

Tribe or band, and location:

Tribe or band, and location:

Tribal membership or enrollment number, if known:

Tribal membership or enrollment number, if known:

If deceased, date and place of death:

If deceased, date and place of death:

ICWA-030 [New January 1, 2008]

NOTICE OF CHILD CUSTODY PROCEEDING FOR INDIAN CHILD
(Indian Child Welfare Act)

Page 5 of 10

ICWA-030
CASE NAME:
CASE NUMBER:

5. f.

INFORMATION ON THE CHILD NAMED IN 1 (Indicate if any of the information requested below is unknown or does not apply; do not use the abbreviation "N/A".)

Indian Custodian Information
Name (include maiden, married, and former names or aliases):

Indian Custodian Information
Name (include maiden, married, and former names or aliases):

Current address:

Current former address:

Former address:

Former address:

Birth date and place:

Birth date and place:

Tribe or band, and location:

Tribe or band, and location:

Tribal membership or enrollment number, if known:

Tribal membership or enrollment number, if known:

6. ADDITIONAL INFORMATION ON CHILD NAMED IN 1 (Indicate if any of the information requested below is unknown.) a. b. c. d. Biological birth father is named on birth certificate. Biological birth father has acknowledged parentage. There has been a judicial declaration of parentage. Other alleged father (name each): Unknown Unknown Unknown

Unknown

The following optional questions may be helpful in tracing the ancestry of the child in 1.

7. Has the child in 1 or any members of his or her family ever (if "yes," provide the information requested below): a. Attended an Indian school? Name/relationship to child Yes Type of school No Unknown Dates attended Name and location of school

ICWA-030 [New January 1, 2008]

NOTICE OF CHILD CUSTODY PROCEEDING FOR INDIAN CHILD
(Indian Child Welfare Act)

Page 6 of 10

ICWA-030
CASE NAME:
CASE NUMBER:

b. Received medical treatment at an Indian health clinic or U.S. Public Health Service hospital? Yes No Unknown Type of treatment Dates of treatment Location where treatment given

Name/relationship to child

c. Lived on federal trust land, a reservation or rancheria, or an allotment? Name/relationship to child

Yes

No

Unknown Dates of residence

Name/description of property and address

d. Other relative information (e.g., aunts, uncles, siblings, first and second cousins, stepparents, etc.) Name/relationship to child Current and former address Birth date and place Tribe, band, and location

8. a.

Tribal affiliation and location of child in 1 (check all that apply): 1906 Final Roll Name of relative listed on roll: Relationship to child in 1: b. Roll of 1924 Name of relative listed on roll: Relationship to child in 1: Roll number, if known:

c.

California Judgment Roll.

ICWA-030 [New January 1, 2008]

NOTICE OF CHILD CUSTODY PROCEEDING FOR INDIAN CHILD
(Indian Child Welfare Act)

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ICWA-030
CASE NAME:
CASE NUMBER:

9. Additional party information (list the name, mailing address, and telephone number of all parties notified) : Name Mailing Address Telephone Number

DECLARATION
(To be completed, dated, and signed in all cases by each petitioner named in companion petition.) I am the petitioner or we are all of the petitioners in this proceeding. In response to items 5­9 of this form, I/we have given all information I/we have about the relatives and, if applicable, the Indian custodian, of the child named in item 1 of this form. I/We 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)

Date:

(TYPE OR PRINT NAME )

(SIGNATURE)

Date:

(TYPE OR PRINT NAME )

(SIGNATURE)

ICWA-030 [New January 1, 2008]

NOTICE OF CHILD CUSTODY PROCEEDING FOR INDIAN CHILD
(Indian Child Welfare Act)

Page 8 of 10

ICWA-030
CASE NAME:
CASE NUMBER:

CERTIFICATE OF MAILING--JUVENILE COURT PROCEEDINGS
(To be completed by social worker or probation officer.) I certify that a copy of the Notice of Child Custody Proceeding for Indian Child, with a copy of the petition identified on page 1 of this form, was mailed as follows. Each copy was enclosed in an envelope with postage for registered or certified mail, return receipt requested, fully prepaid. The envelopes were addressed to each person, tribe, or agency as indicated below. (Except that the telephone numbers shown below were not placed on the envelopes. They are shown below because they must be disclosed in the Notice under Family Code section 180, Probate Code section 1460.2, and Welfare and Institutions Code section 224.2.) Each envelope was sealed and deposited with the United States Postal Service at (place): on (date): . Date: Title: Department:

(TYPE OR PRINT NAME)

(SIGNATURE )

DECLARATION OF MAILING--ADOPTION, FAMILY LAW, AND PROBATE PROCEEDINGS
(To be completed by the attorney for Petitioner if Petitioner is represented.) I am an attorney at law, admitted to practice in the courts of the State of California, and attorney for Petitioner in this matter. I declare that a copy of the Notice of Child Custody Proceeding for Indian Child, with a copy of the petition identified on page 1 of this form, was mailed as follows. Each copy was enclosed in an envelope with postage for registered or certified mail, return receipt requested, fully prepaid. The envelopes were addressed to each person, tribe, or agency as indicated below. (Except that the telephone numbers shown below were not placed on the envelopes. They are shown below because they must be disclosed in the Notice under Family Code section 180, Probate Code section 1460.2, and Welfare and Institutions Code section 224.2.) Each envelope was sealed and deposited with the United States Postal Service at (place): on (date): . 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 ATTORNEY)

CERTIFICATE OF MAILING--PROBATE PROCEEDINGS
(To be completed by the clerk of the court if Petitioner is unrepresented.) I certify that a copy of the Notice of Child Custody Proceeding for Indian Child, with a copy of the petition, was mailed as follows. Each copy was enclosed in an envelope with postage for registered or certified mail, return receipt requested, fully prepaid. The envelopes were addressed to each person, tribe, or agency as indicated below. (Except that the telephone numbers shown below were not placed on the envelopes. They are shown below because they must be disclosed in the Notice under Family Code section 180, Probate Code section 1460.2, and Welfare and Institutions Code section 224.2.) Each envelope was sealed and deposited with the United States Postal Service at (place): on (date): Date: . Title: Department:

(TYPE OR PRINT NAME )

(SIGNATURE)

This form and all return receipts must be filed with the court.
ICWA-030 [New January 1, 2008]

NOTICE OF CHILD CUSTODY PROCEEDING FOR INDIAN CHILD
(Indian Child Welfare Act)

Page 9 of 10

ICWA-030
CASE NAME:
CASE NUMBER:

NAMES, ADDRESSES, AND TELEPHONE NUMBERS OF ALL PERSONS, TRIBES, OR AGENCIES TO WHOM NOTICE WAS MAILED 1. Parent (Name): Street address: Mailing address: City, state and zip code: Telephone number: 2. Parent (Name): Street address: Mailing address: City, state and zip code: Telephone number:

3.

Guardian (Name): Street address: Mailing address: City, state and zip code: Telephone number:

4.

Guardian (Name): Street address: Mailing address: City, state and zip code: Telephone number:

5.

Indian Custodian (Name): Street address: Mailing address: City, state and zip code: Telephone number: Sacramento Area Director Bureau of Indian Affairs 2800 Cottage Way Street address: Sacramento, CA 95825 City and zip code: Telephone number: Tribe (Name): Addressee (Name): Title: Street address: Mailing address: City, state and zip code: Telephone number:

6.

Indian Custodian (Name): Street address: Mailing address: City, state and zip code: Telephone number: Secretary of the Interior U.S. Department of the Interior 1849 C Street, N.W. Street address: Washington D.C. 20240 City, state and zip code: Telephone number: Tribe (Name): Addressee (Name): Title: Street address: Mailing address: City, state and zip code: Telephone number:

7.

8.

9.

10.

11.

Tribe (Name): Addressee (Name): Title: Street address: Mailing address: City, state and zip code: Telephone number:

12.

Tribe (Name): Addressee (Name): Title: Street address: Mailing address: City, state and zip code: Telephone number:

Note: Notice to the tribe must be sent to the tribe chairman or designated authorized agent for service. Additional tribes served listed on attached form ICWA-030(A)
ICWA-030 [New January 1, 2008]

NOTICE OF CHILD CUSTODY PROCEEDING FOR INDIAN CHILD
(Indian Child Welfare Act)

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