Free ICWA-040.v12 101007 mc.ofm - California

ICWA-040
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): 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:

CHILD'S NAME:
CASE NUMBER:

NOTICE OF DESIGNATION OF TRIBAL REPRESENTATIVE AND NOTICE OF INTERVENTION IN A COURT PROCEEDING INVOLVING AN INDIAN CHILD
TO ALL PARTIES: 1. I represent the (name of tribe): Indian tribe listed in the Federal Register. 2. The above named child or children are: Members of this tribe Eligible for membership in this tribe and their Mother

RELATED CASES (if any):

, which is a federally recognized

Father is a member of this tribe.

3. Under the Indian Child Welfare Act, the tribe designates (specify name and title): as the tribe's representative and authorizes that person under the attached tribal resolution other official tribal document (e.g. letter, declaration, or other document from the office of the chairperson or president of the tribe or ICWA office) for the following purposes: a. b. c. d. e. f. g. 4. to receive notice of hearings; to be present at hearings; to address the court; to examine all court documents relating to the case (at the court's discretion, if tribe does not intervene); to submit written reports and recommendations to the court; to request transfer of the case to the tribe's jurisdiction; and to intervene at any point in a proceeding when it is determined the act applies. The tribe is formally intervening as a party and is entitled to be treated in the same manner as counsel.

5. If the tribe is not formally intervening, but wants permission to exercise powers listed in Cal. Rules of Court, rule 5.534(i)(2), this section must be completed and presented to the court for signature prior to service and filing. The tribe does not formally intervene at this time but requests that notice of all proceedings continue to be sent to the tribe. Though not intervening, the tribe requests permission for a representative to exercise the following powers b. (Cal. Rules of Court, rule 5.534(i)(2)): (1) Be present at the hearings; (2) Address the court; (3) Receive notice of hearing; Examine all court documents relating to the case; (4) (5) Submit written reports and recommendations to the courts; and (6) Perform other duties and responsibilities as requested or approved by the court. IT IS SO ORDERED: DATE:
JUDGE (OR JUDICIAL OFFICER) Page 1 of 4 Form Approved for Optional Use Judicial Council of California ICWA-040 [New January 1, 2008]

a.

NOTICE OF DESIGNATION OF TRIBAL REPRESENTATIVE AND NOTICE OF INTERVENTION IN A COURT PROCEEDING INVOLVING AN INDIAN CHILD

Family Code, § 177(a); Probate Code, § 1459.5(b); Welfare and Institutions Code, § 224.4; American LegalNet, Inc. Cal. Rules of Court, rule 5.534(i) www.courtinfo.ca.gov www.FormsWorkflow.com

ICWA-040
CHILD'S NAME:
CASE NUMBER:

6. The tribe requests that notice of all proceedings be sent to the above named tribal representative at the contact information below: Name: Title: Address: City, state, zip code: Telephone: Fax: 7. The tribe below: requests does not request an additional notice be sent to the tribal council at the contact information

Name: Title: Address: City, state, zip code: Telephone:

Fax:

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)

ICWA-040 [New January 1, 2008]

NOTICE OF DESIGNATION OF TRIBAL REPRESENTATIVE AND NOTICE OF INTERVENTION IN A COURT PROCEEDING INVOLVING AN INDIAN CHILD

Page 2 of 4

ICWA-040
CHILD'S NAME:
CASE NUMBER:

PROOF OF SERVICE
ICWA-040, the Notice of Designation of Tribal Representative and Notice of Intervention in a Court Proceeding Involving an Indian Child must be served on the other parties or attorneys for the parties. Anyone at least 18 years of age EXCEPT A PARTY in this action may personally serve or mail the notice. The person who serves the notice must fill out and sign this proof of service. ICWA-040, the Notice of Designation of Tribal Representative and Notice of Intervention in a Court Proceeding Involving an Indian Child may not be filed with the court until all the parties or attorneys are served. 1. 2. At the time of service I was at least 18 years of age and not a party to the legal action. I served a copy of form ICWA-040 and all attachments as follows (check either a or b below for each person served): a. Personal service. I personally delivered a copy of form ICWA-040 and all attachments as follows: (1) Name of child's attorney (if applicable) served: (a) Address: (2) Name of or parent (if self-represented) parent's attorney (if applicable) served:

(a) Address:

(b) Date of delivery: (c) Time of delivery: (3) Name of Court Appointed Special Advocate (if applicable) served: (a) Address:

(b) Date of delivery: (c) Time of delivery: (4) Name of or served: social worker (dependency only) probation officer (delinquency only)

(a) Address: (b) Date of delivery: (c) Time of delivery: (b) Date of delivery: (c) Time of delivery: (5) Name of child's caregiver or Indian custodian served: (a) Address: (6) Attorney for child welfare services agency (dependency only) served: (a) Address:

(b) Date of delivery: (c) Time of delivery:

(b) Date of delivery: (c) Time of delivery:

(7) Name of or

parent (if self-represented) parent's attorney (if applicable) served:

(a) Address:

(8) District Attorney (delinquency only) served: (a) Address:

(b) Date of delivery: (c) Time of delivery:
ICWA-040 [New January 1, 2008]

(b) Date of delivery: (c) Time of delivery:
Page 3 of 4

NOTICE OF DESIGNATION OF TRIBAL REPRESENTATIVE AND NOTICE OF INTERVENTION IN A COURT PROCEEDING INVOLVING AN INDIAN CHILD

ICWA-040
CHILD'S NAME:
CASE NUMBER:

b.

Mail. I deposited a copy of form ICWA-040 and all attachments in the United States mail, in a sealed envelope with postage fully prepaid, addressed as follows: (1) Name of child's attorney (if applicable) served: (a) Address: (2) Name of or parent (if self-represented) parent's attorney (if applicable) served:

(a) Address:

(b) Date of deposit: (c) Place of deposit: (3) Name of Appointed Special Advocate (if applicable) served: (a) Address:

(b) Date of deposit: (c) Place of deposit: (4) Name of or served: social worker (dependency only) probation officer (delinquency only)

(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: (a) Address: (6) Attorney for child welfare services agency (dependency only) served: (a) Address:

(b) Date of deposit: (c) Place of deposit:

(b) Date of deposit: (c) Place of deposit:

(7) Name of or

parent (if self-represented) parent's attorney (if applicable) served:

(a) Address:

(8) District Attorney (delinquency only) served: (a) Address:

(b) Date of deposit: (c) Place of deposit: c.

(b) Date of deposit: (c) Place of deposit:

Attachment. If there are additional persons to serve, attach a separate piece of paper to form ICWA-040, write the child's name and case number on the top, and list additional persons' names, mailing addresses or location of personal service, 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) ICWA-040 [New January 1, 2008]

(SIGNATURE OF PERSON WHO SERVED NOTICE) Page 4 o f 4

NOTICE OF DESIGNATION OF TRIBAL REPRESENTATIVE AND NOTICE OF INTERVENTION IN A COURT PROCEEDING INVOLVING AN INDIAN CHILD