Free ICWA-010(A).v11 101007 mc.ofm - California

ICWA-010(A)
CHILD'S NAME:
CASE NUMBER:

1. Name of child: Indian child inquiry a.

made

not made

and (check all that apply):

The child is or may be a member of or eligible for membership in a tribe. Name of tribe(s): Name of band (if applicable): The child's parents, grandparents, or great-grandparents are or were members of a tribe. Name of tribe(s): Name of band (if applicable):

b.

c. d.

The residence or domicile of the child, child's parents, or Indian custodian is in a predominantly Indian community. The child or the child's family has received services or benefits from a tribe or services that are available to Indians from tribes or the federal government, such as the Indian Health Service or Tribal Temporary Assistance to Needy Families (TANF). The child may have Indian ancestry. The child has no known Indian ancestry. Other reason to know the child may be an Indian child: Person(s) questioned: Name: Address: City, state, zip: Telephone: Date questioned: Means of communication: Relationship to child: Summary of information: Person(s) questioned: Name: Address: City, state, zip: Telephone: Date questioned: Means of communication: Relationship to child: Summary of information:

e. f. g.

h.

Information about other persons questioned is attached.

2. If this is a delinquency proceeding under Welfare and Institutions Code, § 601 or 602: The child is in foster care. It is probable the child will be entering foster care.

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date:
(TYPE OR PRINT NAME) (SIGNATURE)

Page 1 of ____ Form Adopted for Mandatory Use Judicial Council of California ICWA-010(A) [New January 1, 2008]

INDIAN CHILD INQUIRY ATTACHMENT

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