SDSC D-243 (New 4/09) CONSENT TO CUSTODY OF AN INDIAN CHILD Fam. Code 247 3041 TO NON-PARENT AND COURT CERTIFICATION 25 U.S.C 2471913 Page 1 of 2 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): TELEPHONE NO.: FAX NO.(Optional): ATTORNEY FOR (Name): FOR COURT USE ONLY SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN DIEGO CENTRAL DIVISION, CENTRAL COURTHOUSE, 1100 UNION ST., SAN DIEGO, CA 92101 CENTRAL DIVISION, FAMILY COURT, 1555 6TH AVE., SAN DIEGO, CA 92101 CENTRAL DIVISION, MADGE BRADLEY, 1409 4TH AVE., SAN DIEGO, CA 92101 EAST COUNTY DIVISION, 250 E. MAIN ST., EL CAJON, CA 92020 NORTH COUNTY DIVISION, 325 S. MELROSE DR., VISTA, CA 92081 SOUTH COUNTY DIVISION, 500 3RD AVE., CHULA VISTA, CA 91910 PETITIONER(S) THIRD - PARTY CLAIMANT(S) CONSENT TO CUSTODY OF AN INDIAN CHILD TO NON-PARENT AND COURT CERTIFICATION CASE NUMBER 1. Your Name: Mother Father Custodian (Check only one. Each parent/custodian must complete a separate form.) 2. Your Address: City: State: Zip Code: Telephone Number: 3. Your Name of Tribe(s)/Band(s): Check here if you do not know the enrollment number. 4. Name of Indian Child: Date of Birth: Age: (Note: Consent not valid unless child is at least 10 days old.) 5. Indian Tribe(s)/Band(s) of Which Child is a Member or Eligible for Membership: Child222s Enrollment Number: Check here if you do not know the enrollment number. 6. In contemplation of the pending custody claim under California Fam.Code 247 3041, I VOLUNTARILY CONSENT AND AGREE: (Check only one) a. shall have partial legal and/or physical custody of the child named above. (Name of Non-Parent) b. shall have full legal and physical custody of the child named above. (Name of Non-Parent) American LegalNet, Inc. www.FormsWorkFlow.com SDSC D-243 (New 4/09) CONSENT TO CUSTODY OF AN INDIAN CHILD Fam. Code 247 3041 TO NON-PARENT AND COURT CERTIFICATION 25 U.S.C 2471913 Page 2 of 2 CASE TITLE CASE NUMBER 7. Relationship of Non-Parent to Indian Child: 8. Address of Non-Parent: City: State: Zip Code: Telephone Number: By signing below, I am certifying I know and fully understand the terms and consequences of this consent. I understand I am not waiving my rights under the Indian Child Welfare Act (25 U.S.C. 247 1901 et seq.). I understand I may withdraw and revoke my consent at any time and for any reason, and upon such withdrawal of consent, all provisions of the Indian Child Welfare Act shall apply. Pursuant to 25 U.S.C 247 1913(b), I further understand that upon withdrawal of my consent, my child shall be returned to me as soon as is practicable. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: Type or Print Name Signature of Indian Parent/Custodian JUDGE222S CERTIFICATION Pursuant to 25 U.S.C 247 1913(a), I, Judge/Commissioner , of the Superior Court of California, County of San Diego, hereby certify: consent was completed in writing and recorded before me. of this consent to (name of parent/custodian): parent/custodian fully understood the terms and consequences of this consent. /custodian understands English or the hearing was interpreted into a language the parent/custodian understood. Date: Judge/Commissioner of the Superior Court American LegalNet, Inc. www.FormsWorkFlow.com