MANDATORY REPORTING FORM FOR ALL ADOPTION CASES (Must Be Completed And Provided With Case Filing Statement) Birth Name of Child _____________________________________________________________________________________________ Last Name First Name Middle Initial Name and Address of Biological Father _____________________________________________________________________________________________ Last Name First Name Middle Initial _____________________________________________________________________________________________ Address _____________________________________________________________________________________________ City State Zip Name and Address of Biological Mother _____________________________________________________________________________________________ Last Name First Name Middle Initial _____________________________________________________________________________________________ Address _____________________________________________________________________________________________ City State Zip ICWA Information: Name and Address of Tribal Affiliation _____________________________________________________________________________________________ Tribal Affiliation _____________________________________________________________________________________________ Address _____________________________________________________________________________________________ City State Zip Name and Address of any Agency having files or information relating to the Adoptive Placement (Please list additional agencies on the back of this form.) _____________________________________________________________________________________________ Agency _____________________________________________________________________________________________ Address _____________________________________________________________________________________________ City State Zip FOR CLERK OF COURT OFFICE ONLY IF IT IS AN ICWA CASE, ATTACH AFFIDAVITS OF BIOLOGICAL PARENTS (IF ANY) TO THIS FORM AND SEND TO THE FOLLOWING ADDRESS: SECRETARY, BUREAU OF INDIAN AFFAIRS U.S. DEPARTMENT OF INTERIOR 1849 C STREET NW WASHINGTON, DC 20240 Form UJS-354 Rev. 01/2008 American LegalNet, Inc. www.FormsWorkFlow.com