Fill and Sign the General Form 31

F,C.A. §115(d); S.S.L. §39 General Form 31 25 U.S.C. §§1901-1963 (Affidavit relating to Indian Child Welfare Act ) 10/2012 FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF ................................................... .......................................... Docket No. In the Matter of a Proceeding Docket No. AFFIDAVIT RELATING TO Indian Child Welfare Act ................................................... .......................................... STATE OF NEW YORK ) ):ss: COUNTY OF ) I, [specify name]: ” swear ” affirm the following to be true under the penalties of perjury: 1. I am the [check applicable box]: ” father ” mother ” Indian custodian of the child ” Chief of the [specify tribe or nation]: ” Other representative of the tribe or nation [speci fy title and tribe or nation]: ” Commissioner of Social Services of the County of [ specify]: ” Commissioner of the New York City Administration f or Children’s Services ” Other [specify relation to child and/or title or position and agency]: 2. (Upon information and belief) the child involved in the above-named proceeding is [check all applicable box(es)]:: ” a member ” eligible to be a member ” a child of a member 1 ” a Native-American child who is a ward of the triba l or nation court ” a Native-American child who is domiciled or residi ng on the tribal reservation or tribal lands of the following tribe or nation [specify]: , a tribe or nation recognized by the ” Bureau of Indian Affairs, US Dept of the Interior ” State of New York ” Other state [specify]: 3.This statement is based upon the following facts and information: My Name (Signature o f Affirmant or Affiant) Sworn to before me this day of , (Deputy) Clerk of the Court 1 The parent member includes: birth mother, father ma rried to birth mother at time of the birth or father who signed an acknowledgment of paternity or obtained a n order of filiation and Native-American adoptive parent of a Native-American child. See 25 U.S.C. §1903(9). Notary Public