IW-1783A, 05/14 Consent to Delegation of Powers under 24748.979, Wisconsin Statutes of an Indian Child 24724748.028(5) and 48.979, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional information. Page 1 of 1 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE INTEREST OF Name Date of Birth Consent to Delegation of Powers under 24748.979, Wis. Stats. of an Indian Child Case No. UNDER OATH, I STATE: 1. My name is My address is My date of birth is 2. I am the [check one] mother. father. 3. I have legal custody of the child named above. 4. My child is a member of an Indian tribe or is eligible for membership in an Indian tribe and is the biological child of a member of an Indian tribe. 5. My child is at least 11 days old. 6. The proposed power of attorney delegating parental power is attached. 7. The terms and consequences of the delegation of powers have been fully explained in detail and in my own language. I understand that I am delegating my powers regarding the care and custody of my child to an agent, as set forth in the attached power of attorney document. 8. I am making this decision of my own free will. No promises or threats have been made to get me to sign this document. 9. My consent may be withdrawn for any reason at any time. Signature Name Printed or Typed Da te American LegalNet, Inc. www.FormsWorkFlow.com