ADOPT-220 Adoption of Indian Child This form is attached to Adoption Request (ADOPT-200). 1 Your name (adopting parent): a. b. Relationship to child: Address (skip this if you have a lawyer): Street: City: State: Zip: ) Telephone number: ( Lawyer (if any): (Name, address, telephone number, and State Bar number): Clerk stamps date here when form is filed. Fill in court name and street address: Superior Court of California, County of Fill in case number if known: Case Number: Federal law says the state courts must send a copy of all adoption orders for an Indian child to the Secretary of the Interior within 30 days. The state court must also send the following information Please complete the rest of the form. 2 Indian child's name: Date of birth: Age: 3 Indian child's tribe (or tribe child is eligible for): Enrollment #: Check here if you do not know. Check here if tribe does not have an enrollment number. 4 Indian child's biological mother (name): Street address: City: State: Zip: Check here if you do not know. The biological mother attaches her request that her identity remain confidential. 5 Indian child's biological father (name): Street address: City: State: Zip: Check here if you do not know. The biological father attaches his request that his identity remain confidential. Judicial Council of California, www.courts.ca.gov Revised July 1, 2010, Mandatory Form 25 U.S.C. § 1951 Adoption of Indian Child ADOPT-220, Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Case Number: Your name: 6 Indian child's biological Indian grandmothers (names; include maiden names if you know them): Check here if you do not know. 7 Indian child's biological Indian grandfathers (names): Check here if you do not know. 8 Name of any agency with information about this adoption: 9 Other people with information about the Indian child's ancestry: Name a. b. c. Relationship to Child 10 Parental rights (check all that apply): a. A court ended parental rights on (date): b. c. Parental rights were modified under a tribal customary adoption order on (date): Parents voluntarily agreed in writing to end their parental rights. (1) ADOPT-225 will be recorded in front of a judge and filed with the court before the adoption hearing on (date): (2) (3) d. 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. 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. (1) (2) 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. 11 Note: The court will notify the American Indian tribe of the child's adoption. Revised July 1, 2010 Adoption of Indian Child ADOPT-220, Page 2 of 2