SDSC JUV-268 (New 12/17) CHILD’S ICWA FORM Page 1 of 3

Cal. Form JUV-268

California Superior Local Rules

SDSC JUV-268 (New 12/17) CHILD’S ICWA FORM SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN DIEGO CHILD’S ICWA FORM Child’s Name: DOB (date of birth): Petition #: Child’s 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: Today’s Date: / / 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: The Child’s Tribe(s)/Band(s): Location(s): Enrollment#/CDIB: Parents Child’s biological mother: Child’s biological father: DOB: / / Birthplace: DOB: / / Birthplace: 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 Child’s maternal grandmother (mother’s mother): Child’s maternal grandfather (mother’s father) DOB: / / Birthplace: DOB: / / Birthplace: 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?

SDSC JUV-268 (New 12/17) CHILD’S ICWA FORM Child’s Name: DOB: / / Petition #: Paternal Grandparents Child’s paternal grandmother (father’s mother): Child’s paternal grandfather (father’s father): DOB: / / Birthplace: DOB: / / Birthplace: 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 Child’s maternal great grandmother (mother’s grandmother): Child’s maternal great grandfather (mother’s grandfather): DOB: / / Birthplace: DOB: / / Birthplace: 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 Child’s maternal great grandmother (mother’s other grandmother): Child’s maternal great grandfather (mother’s other grandfather): DOB: / / Birthplace: DOB: / / Birthplace: 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 Child’s paternal great grandmother (father’s grandmother): Child’s paternal great grandfather (father’s grandfather): DOB: / / Birthplace: DOB: / / Birthplace: 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? SDSC JUV-268 (New 12/17) CHILD’S ICWA FORM Child’s Name: DOB: / / Petition #: Pat.

Great Grandparents Child’s paternal great grandmother (father’s other grandmother): Child’s paternal great grandfather (father’s other grandfather): DOB: / / Birthplace: DOB: / / Birthplace: 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 Final Roll? Yes No  or the 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 your family who would have additional information? Name: Phone: Relationship to Child: Any Additional Information Provide any additional information you have about the child’s Native American heritage:

Document details

Collection	California Superior Local Rules
Citation	Cal. Form JUV-268
Type	court_rule
Language	en
Format	pdf
Source	CA_LOCAL
Identifier	6f3d72a371afc45309ebcc8f25a160a17fda192a

Source file is stored in the law ingest library (pdf).