STATE OF NEBRASKA FORM NO. CC 17:4 3/87 NEW
NOTICE OF ADOPTIVE PLACEMENT OF AN INDIAN CHILD
CASE NUMBER
IN THE COUNTY COURT OF _____________________________COUNTY, NEBRASKA IN THE MATTER OF THE ADOPTION OF
NOTICE OF ADOPTIVE PLACEMENT OF AN INDIAN CHILD
, a minor.
On
,
, , Nebraska.
an Indian child was placed for adoption in the county court of
NAME OF CHILD TRIBAL AFFILIATION OF CHILD NAME OF BIOLOGICAL MOTHER ADDRESS NAME OF BIOLOGICAL FATHER ADDRESS NAME OF BIOLOGICAL MOTHER ADDRESS NAME OF BIOLOGICAL FATHER ADDRESS AGENCY HAVING INFORMATION RELATING TO PLACEMENT
Copy of affidavit of the biological parents that their identity remain confidential accompanies this Notice. No affidavit of the biological parents relating to confidentiality was filed with the petition.
DATE: BY THE COURT: (Seal)