Consent to Foster Care Placement by Indian Child222s - Page 1 of 2 Parents or Indian Custodian (CON) WPF JU 03.0920 (07/2018) 226 RCW 13.38.150; 25 U.S.C. 247 1913; 25 C.F.R. 247 23.124 - .127 Superior Court of Washington County of Juvenile Court Dependency of: D.O.B.: No : Consent to Foster Care Placement by Indian Child222s Parent or Indian Custodian (CON) I. Consent 1.1 I am the parent Indian Custodian of the above identified child. The child was born more than ten (10) days prior to the date on which I signed this consent. 1.2 There is reason to know the child is: (1) a member of a federally recognized tribe, or (2) eligible for membership in a federally recognized tribe and the biological child of a parent who is a member, based upon the following: . 1.2.1 The name of the above identified child222s tribe or tribes is: . 1.2.2 The child222s and parent222s/parents222 tribal membership/enrollment numbers or other indication of the child222s membership in the tribe is as follows: . 1.3 I understand that I have the right to obtain the advice and representation of an attorney regarding foster care placement. 1.4 I confirm that I desire to and hereby consent to release custody of the child to the Department of Children, Youth, and Families and hereby authorize the agency to have custody of the child and to have the power and authority to authorize and provide all necessary care for the child, which shall include but not be limited to, foster care, medical care, dental care, and evaluations of the child. 1.5 I understand that I can withdraw consent to a foster care placement at any time, and my child shall be returned to me. 1.6 I understand that this consent is not valid and has no force and effect unless I sign the consent in court and unless the consent is approved by the court. 1.7 The address of the clerk of the court where the consent will be presented for court approval is: . American LegalNet, Inc. www.FormsWorkFlow.com Consent to Foster Care Placement by Indian Child222s - Page 2 of 2 Parents or Indian Custodian (CON) WPF JU 03.0920 (07/2018) 226 RCW 13.38.150; 25 U.S.C. 247 1913; 25 C.F.R. 247 23.124 - .127 1.8 I have read or have had read to me the foregoing and I understand the same. The foregoing consent has been given freely, voluntarily, and with full knowledge of the consequences as stated above, and the consent is not the result of fraud or duress, nor am I acting under the influence of anyone. I certify under penalty of perjury under the laws of the state of Washington that the foregoing statement is true and correct. Dated at (city), (state) on (date). Signature Print or Type Name Address Telephone Number Signature of Parent222s Lawyer Print or Type Name WSBA No. II. Parent222s or Indian Custodian222s In-Court Declaration and Signature This section must be completed in Court in the presence of a Judge/Commissioner. I declare under penalty of perjury under the laws of the state of Washington that I wish to consent to foster care placement for my child as provided in the foregoing consent and that the information in the consent is true and correct. Signed at (city), in (state) on , (date). Signature of Parent/Indian Custodian III. Court Certification Pursuant to, the Indian Welfare Act of 1978, 25 U.S.C. 247 1913(a) and RCW 13.38.150, I certify that this consent was executed by the parent or Indian custodian in writing and recorded before me; that the terms and consequences of the consent were fully explained in detail in English or in the parent's or Indian Custodian222s primary language, and that the parent fully understood the consequences of giving such consent. Certified on (date). Judge/Court Commissioner IV. Interpreter Declaration I am a certified or registered interpreter, or have been found otherwise qualified by the court to interpret in the language, which the parent or Indian Custodian understands. I have translated this document for parent or Indian Custodian from English into that language. I certify under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct. Signed at (city) , (state) , on (date) . Interpreter Print Name American LegalNet, Inc. www.FormsWorkFlow.com