Fill and Sign the Wa Child Welfare Form

SUPERIOR COURT OF WASHINGTON COUNTY OF _______________________ JUVENILE COURT In the Interest of: D.O.B.: NO: Indian Child Welfare Act Notice (Federal and Washington State) (BIAN) Access is Restricted Per GR 22(c)(3) and 25 C.F.R. § 23.111(d)(6)(ix) To : (Parents, Indian Custodian, and Child’s Tribe(s)) This notice is given pursuant to the Indian Child Welfare Act, 25 U.S.C. § 1912 and RCW 13.38.070. A child custody proceeding involving the child named above is pending in the court named above. A copy of the petition is attached. There is reason to know that the child named above is (1) a member or (2) is the biological child of a member and is eligible for membership in the Tribe(s). 1. Information on the Child Name: Present Residence: Date and Place of Birth: Where child was taken into custody: Tribal affiliation(s), enrollment number(s) or other identifying information: Indian Child Welfare Act Notice (BIAN) – Page 1 of 5 WPF JU 05.0250 (10/2017) – RCW 13.32A.152(3), RCW 13.38.070 GR 22(c)(3), 25 C.F.R. § 23. 111, 25. U.S.C. § 1912(a) 2. Information on the Parents (and Indian Custodian, if applicable) Mother : biological adoptive a. Name (all known names including maiden, married and former names or aliases): b. Address: c. Date and Place of Birth: d. Tribal affiliation(s), enrollment number(s), or other identifying information: Father : biological (paternity established) alleged (paternity not est.) presumed/legal adoptive a. Name (all known names including former names or aliases): b. Address: c. Date and Place of Birth: d. Tribal affiliation(s), enrollment number(s), or other identifying information: Other (if applicable) : __________________________________________________ biological (paternity established) alleged (paternity not est.) presumed/legal adoptive a. Name (all known names including former names or aliases): b. Address: c. Date and Place of Birth: d. Tribal affiliation(s), enrollment number(s), or other identifying information: Indian Child Welfare Act Notice (BIAN) – Page 2 of 5 WPF JU 05.0250 (10/2017) – RCW 13.32A.152(3), RCW 13.38.070 GR 22(c)(3), 25 C.F.R. § 23. 111, 25. U.S.C. § 1912(a) If applicable, Indian Custodian : Name (all known names including former names or aliases): a. Address: b. Date and Place of Birth: c. Tribal affiliation(s), enrollment number(s), or other identifying information: d. Circumstances of Indian custodianship (e.g., does person have legal or temporary physical custody of child under tribal or state law? Has parent transferred temporary care, physical custody, and control of the child?) ___________________________________________________________ ___________________________________________________________ 3. All Known Maternal Grandparents, Paternal Grandparents, Great Grandparents List names and maiden names; current and former addresses; dates and places of birth and death; tribal affiliations; enrollment numbers; other identifying information about: Maternal Grandparents: Paternal Grandparents: . Great Grandparents: Indian Child Welfare Act Notice (BIAN) – Page 3 of 5 WPF JU 05.0250 (10/2017) – RCW 13.32A.152(3), RCW 13.38.070 GR 22(c)(3), 25 C.F.R. § 23. 111, 25. U.S.C. § 1912(a) 4. Petitioner in This Proceeding a. Name: b. Address: c. Phone Number: 5. Attorney for the Petitioner a. Name: b. Address: c. Phone Number: The petition has been filed in the Superior Court for ______________________ County, State of Washington. A hearing is scheduled on __________________________ [date], at ____________a.m./p.m. The address of the court is . The phone number of the court is . The hearing will take place in courtroom . No proceeding involving the child named above shall take place until at least ten (10) days after receipt of this notice. The child’s Tribe(s), the biological parents, and any Indian custodian (if applicable) of the child named above each have the right to request up to 20 additional days to prepare for the child-custody proceeding. The child’s Tribe(s), the biological parents, and any Indian custodian of the child named above each have the right to intervene and be made a party in this proceeding under the Indian Child Welfare Act. The child’s Tribe(s) has the right to intervene at any time in this state court proceeding for the out-of-home placement of or termination of parental rights to an Indian Child. If the parents or Indian custodian (if applicable) are unable to afford counsel, counsel will be appointed to represent them. The parents or Indian custodian have the right to be represented by an attorney at every stage of this proceeding. The court may, in its discretion, appoint an attorney to represent the child named above. The child’s Tribe(s), the parents, or the Indian custodian (if applicable) of the child named above have the right, upon request, to examine all documents or other material which may be used to make a decision in this matter. Such request shall be made in writing to the court clerk, or the Court at the hearing. They also have the right to petition the court to transfer this proceeding to the courts of the child’s Tribe(s). Such petition may be made orally on the record or in writing, at any time and at any stage of the proceeding. The petition shall be granted unless either parent objects, the Tribal court declines the transfer, or good cause in accordance with 25 C.F.R. § 23.118 is found by the Court. Indian Child Welfare Act Notice (BIAN) – Page 4 of 5 WPF JU 05.0250 (10/2017) – RCW 13.32A.152(3), RCW 13.38.070 GR 22(c)(3), 25 C.F.R. § 23. 111, 25. U.S.C. § 1912(a) A decision in this matter may affect the future parental and/or custodial rights of the child’s Tribe(s), the parents, and (if applicable) the Indian custodian of the child named above, and may result in the temporary or permanent removal of the child from his or her home. The information contained in this notice and the attached petition is confidential and should not be disclosed or revealed to any person or agency which is not necessary for proper notification of the parents, Indian custodian or the Tribe(s) of the above-named minor child, and which is not necessary for the exercise of their rights under the Indian Child Welfare Act . (25 C.F.R. §23.111(d)(6)(ix) . ) This notice and the attached pleadings have been sent by certified mail, return receipt requested, to the parents, Indian custodian, if applicable, and the child’s Tribe(s) (Agent designated by the child’s Tribe(s) to receive ICWA notices, as published in the federal register, https://www.federalregister.gov/ (search “ICWA Notice.”) on the date as stated in the Proof of Mailing. On the date as stated in the Proof of Mailing, copy of this notice and the attached pleadings have also been sent by certified mail, return receipt requested to: Portland Area Director Bureau of Indian Affairs 911 NE 11 th Avenue Portland, OR 97232 Signature of Petitioner or Lawyer/WSBA No. Date Indian Child Welfare Act Notice (BIAN) – Page 5 of 5 WPF JU 05.0250 (10/2017) – RCW 13.32A.152(3), RCW 13.38.070 GR 22(c)(3), 25 C.F.R. § 23. 111, 25. U.S.C. § 1912(a)