IW-1783B, 11/17 Certification to Delegation of Powers under 24748.979, Wis. Stats., 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 Certificate to Delegation of Powers under 24748.979, Wis. Stats., of an Indian Child Case No. A Consent to Delegation of Powers of an Indian Child was filed by [Parent Name] on [Date] . I certify that I am the judge of the circuit court of County, State of Wisconsin, a court of record. The above named parent appeared before me on this date. The terms and consequences of the delegation of powers, including the limitation on withdrawing the consent, have been fully explained in detail and were fully understood by the parent, and I found this consent to be informed and voluntary before I accepted it. American LegalNet, Inc. www.FormsWorkFlow.com