CONFIDENTIAL COURT RECORD IW-1649, 11/17 Indian Child Adoptee Information 24748.028, Wisconsin Statutes; 25 CFR 24723.140. This form shall not be modified. It may be supplemented with additional material. Page 1 of 1 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE INTEREST OF Name Date of Birth Indian Child Adoptee Information Indian Child Welfare Act Case No. To: Bureau of Indian Affairs Chief, Division of Human Services 1849 C Street NW Mail Stop 4513 MIB Washington, DC 20240 The court hereby provides the following information regarding the Indian child adoptee: 1. Chi 2. 3. An affidavit signed by a biological parent asking that his or her identity remain confidential is attached. 4 . 5 . Name and contact information for any agency having files or information relating to the adoption : 6. The child is a member of the following tribe: OR eligible for enrollment in the following tribe: AND t father is a member of the following tribe: mother is a member of the following tribe: 7 . A dditional information relating to Tribal membership or eligibility for Tribal membership of the adopted child: See attached 8. The Order for Adoption is attached. DISTRIBUTION: 1. Court 2. Bureau of Indian Affairs American LegalNet, Inc. www.FormsWorkFlow.com