Childs ICWA Form {JUV-268}

SDSC JUV - 268 ( New 12 /17 ) CWA FORM Page 1 of 3 SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN DIEGO ICWA FORM DOB (date of birth): Petition #: ICWA Inquiry Worksheet (Indian Child Welfare Act ) Instructions: Name = full names and any maiden, married, former names, or aliases. Please complete all sections with as much information as you know. Please fill out one form per child if they have different parents. Return form to the assigned social worker, court officer, or your juvenile court attorney. Your Info Your Name: Your relationship to the child: Indian Custodian Guardian Other: Is the child currently a member of a tribe? Yes No Unknown If you are a relative or Indian Custodian of the child: Your Tribe(s)/Band(s): Location(s): Enrollment#/CDIB: (Certificate of Degree of Indian Blood) Any information you know regarding: Location(s): Enrollment#/CDIB: Parents DOB: / / Birthp lace: DOB: / / Birthp lace: Address: Phone: Address: Phone: Tribe(s)/Band(s): Location(s): Enrollment#/CDIB: Tribe(s)/Band(s): Location(s): Enrollment#/CDIB: Deceased? Yes No When? / / Where? Deceased? Yes No When? / / Where? Maternal Grandparents father) DOB: / / Birthp lace: DOB: / / Birthp lace: Address: Phone: Address: Phone: Tribe(s)/Band(s): Location(s): Enrollment#/CDIB: Tribe(s)/Band(s): Location(s): Enrollment#/CDIB: Deceased? Yes No When? / / Where? Deceased? Yes No When? / / Where? American LegalNet, Inc. www.FormsWorkFlow.com SDSC JUV - 268 ( New 12 /17 ) CWA FORM Page 2 of 3 DOB: / / Petition #: Paternal Grandparents p aternal grandmother ( mother): aternal grandfather ( fathe r): DOB: / / Birthp lace: DOB: / / Birthp lace: Address: Phone: Address: Phone: Tribe(s)/Band(s): Location(s): Enrollment#/CDIB: Tribe(s)/Band(s): Location(s): Enrollment#/CDIB: Deceased? Yes No When? / / Where? Deceased? Yes No When? / / Where? Mat. Great Grandparents grandmother): grandfather): DOB: / / Birthp lace: DOB: / / Birthp lace: Address: Phone: Address: Phone: Tribe(s)/Band(s): Location(s): Enrollment#/CDIB: Tribe(s)/Band(s): Location(s): Enrollment#/CDIB: Deceased? Yes No When? / / Where? Deceased? Yes No When? / / Where? Mat. Great Grandparents other grandmother): grandfather): DOB: / / Birthp lace: DOB: / / Birthp lace: Address: Phone: Address: Phone: Tribe(s)/Band(s): Location(s): Enrollment#/CDIB: Tribe(s)/Band(s): Location(s): Enrollment#/CDIB: Deceased? Yes No When? / / Where? Deceased? Yes No When? / / Where? Pat. Great Grandparents grandmother): grandfather): DOB: / / Birthp lace: DOB: / / Birthp lace: Address: Phone: Address: Phone: Tribe(s)/Band(s): Location(s): Enrollment#/CDIB: Tribe(s)/Band(s): Location(s): Enrollment#/CDIB: Deceased? Yes No When? / / Where? Deceased? Yes No When? / / Where? American LegalNet, Inc. www.FormsWorkFlow.com SDSC JUV - 268 ( New 12 /17 ) CWA FORM Page 3 of 3 / Petition #: Pat. Great Grandparents grandmother): grandfather): DOB: / / Birthp lace: DOB: / / Birthp lace: Address: Phone: Address: Phone: Tribe(s)/Band(s): Location(s): Enrollment#/CDIB: Tribe(s)/Band(s): Location(s): Enrollment#/CDIB: Deceased? Yes No When? / / Where? Deceased? Yes No When? / / Where? Additional Family Info Have any family members: Name, Contact Info., and Tribe(s)/Band(s) Attended an Indian School? Yes No Been treated by an Indian Health Clinic? Yes No Lived on a reservation? Yes No Been listed on the 1906 Final Roll? Yes No or the 1924 Roll? Yes No or the California Judgment Roll? Yes No Does the child have any other relatives who are or were members of a tribe/band? Yes No Name(s) and relationship to child (e.g., aunt, cousin, stepparent): Tribe(s)/Bands(s): Is there someone in yo ur family who would have additional information? Name: Phone: Relationship to Child: Any Additional Information American LegalNet, Inc. www.FormsWorkFlow.com