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ADOPT-220 Adoption of Indian Child Yo ur nam e (ado pting parent): Relat ionship to child: Address (skip this if you have a lawy er): Street: Stat e: Zip: City: ADOPT-220, Page 1 of 2 a. b. La wyer (if an y): (Na me, a ddress, teleph on e n umb er, an d Sta te Bar number ): Teleph on e nu mber: () Cler k st amps date here when form is filed. Fill in court name and street address: Su per ior Co urt of Cali forn ia, Cou nty of Case Numb er: Fill in case number if known: 1 This f orm is attached to Ad optio n Re qu est (ADOPT-200). Federal law says the state courts must send a co py of all ad op tio n ord ers for an Indian child to the Sec reta ry of the Interior within 30 days. The stat e court must also send the fo llowing i nformat ion Please complete the rest of the form. Indian chi ld’s name: Date of birth: Age: Indian chi ld’s tribe (or trib e chi ld is eligibl e for ): Enrollment #: Chec k here if you do not know. Chec k here if tribe does not have an enrollment number. Indian child’s biological mothe r (name): Stree t address : Zip: State: City: Check here if you do not know. The biological mot her att aches her request that her identity remain confidential. Indian child’s biological father (name ): Stree t address : Zip: State: City: Check he re if you do not know. The biological fa ther atta ches his reques t tha t his id entit y remain confidential. 23 4 5 Adoption of Indian Child 25 U.S.C. § 19 51 Revised July 1, 2010, Mandatory Fo rm Judicia l Cou ncil of Cali fornia ADOPT-220, Page 2 of 2 Revised July 1, 2010 Your name: Case Number: Indian child’s biological Indian grandmothers (names; include maiden names if you know them): Check here if you do not know. Indian child’s biological Indian grandfathers (names): Check here if you do not know. Name of any agency with information about this adoption: Other people with information about the Indian child’s ancestry: Name Relationship to Child Parental rights (check all that apply): A court ended parental rights on (date): Parents voluntarily agreed in writing to end their parental rights. ADOPT-225 will be recorded in front of a judge and filed with the court before the adoption hearing on (date): ADOPT-225 was recorded in front of a judge and is attached to ADOPT-200 (Adoption Request). ADOPT-225 was signed at least 10 days after the birth date of the Indian child. (3) A judge has certified that he or she fully explained the terms and consequences of the parents’ agreement to end parental rights and that the parents understood. This certificate was filed with the court on (date): ; OR This certificate is attached to ADOPT-200 or will be filed before the adoption hearing. Note: The court will notify the American Indian tribe of the child’s adoption. a. b. c. a. c. (1) (2) d. (2) (1)Parental rights were modified under a tribal customary adoption order on (date): b. 6 7 8 10 9 11 Adoption of Indian Child