DESIGNATION OF AMERICAN INDIAN STATUS CASE(S) NUMBER: NAME OF CHILD/CHILDREN: I, child/children, hereby declare that: () () , parent/guardian of the above named minor There are no known American Indian ancestry for this children/children. The maternal or paternal ancestry includes American Indian relatives. If so, please state the name and relationship of any persons claiming American Indian ancestry for this child/children, the name of the Tribe, and whether or not any relative is an enrolled member of that Tribe, if known. Parent/Guardian signature Designation of American Indian Status Local Form C-40 Mandatory Form Effective 07/14/11 Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com