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Forms: Indian Child Welfare Act

The following information and forms are helpful for social work professionals, tribal workers, attorneys, and others dealing with adoptions or placements involving American Indian children.

Summary of ICWA Jurisdictional Provisions
This is a flow chart that indicates when ICWA does and does not apply to a child.
(Form #1 - 26kb rtf) (Form #1 - 7kb pdf)
Notice Pursuant to ICWA
This form is for the court or county agency's use. The form gives notice to a tribe of any hearing being held on behalf of an Indian Child, including a removal order, shelter care order, or termination of parental rights, that might result in a foster care placement, guardianship, or termination of parental rights. This form should be used whenever there is a child who is believed to be, or has been determined to be an Indian Child. The notice should be sent to all potential tribal affiliations.
(Form #2 - 35kb rtf) (Form #2 - 9kb pdf)
Request for Confirmation of Child's Status as Indian
This form is for a social worker's use. The purpose is to record information related to the child and the child's extended family, and to request from the tribe, a confirmation of the child's status as Indian. The social worker should include as much information as is available regarding the child's extended family. The questions on the form should be posed to birth parents of the child at initial contact. Get as much information as possible! Also note that question #3 provides a guideline for questions to ask birth parents and should be used in all cases, in order to assess Indian status.
(Form #3 - 57kb rtf) (Form #3 - 17kb pdf)
Notice to Secretary of U.S. Dept. of Interior Regarding an Indian Child
This form is for the use of the county when an Indian Child's status cannot be confirmed. When the county is unable to provide notice to a particular tribe because it is unable to verify the child's affiliation, notice must be provided to the Secretary of United States Department of the Interior. Attach the "Request for Confirmation of Child's Status as Indian." (See reference guide of contacts included in this manual).
(Form #4 - 21kb rtf) (Form #4 - 8kb pdf)
Letter from Tribal ICWA Worker
This is a cover letter that Tribe's may choose to use. The letter contains preliminary information as to the status of a child, and the Tribe's intentions regarding jurisdiction, intervention, and placement preferences.
(Form #5 - 26kb rtf) (Form #5 - 10kb pdf)
Letter to Clerk of Court
This is a cover letter for the Tribe's use as they are contacting the District Court regarding intervention.
(Form #6 - 21kb rtf) (Form #6 - 8kb pdf)
Notice of Intervention
This is the actual Notice of Intervention. This is for the Tribe's use when intervening in a District Court case regarding an Indian Child. It can be signed by the Court accepting intervention.
(Form #7 - 23kb rtf) (Form #7 - 9kb pdf)
Request for Transfer
This form is used by the Tribe to request transfer of a case being heard in District Court to Tribal Court.
(Form #8 - 20kb rtf) (Form #8 - 7kb pdf)
Request for Continuance - Indian Tribe
This form is for the Tribe's use when they desire to request a continuance in a hearing regarding an Indian Child.
(Form #9 - 21kb rtf) (Form #9 - 7kb pdf)
Affidavit of Tribal Membership
This form is for the Tribe's use to provide verification of the status of membership for the father, mother, and child. This is an optional form.
(Form #10 - 20kb rtf) (Form #10 - 4kb pdf)
Certificate of Mailing
This form is for the Tribe's use. The form should be included with the Notice of Intervention, Affidavit of Tribal Membership, and/or Request for Transfer.
(Form #11 - 20kb rtf) (Form #11 - 4kb pdf)
Tribal Placement Preferences
This form is for the Tribe's use. The form indicates the Tribe's placement preferences, if different than what is established in ICWA.
(Form #12 - 21kb rtf) (Form #12 - 5kb pdf)
Order for Good Cause/Record of ICWA Placement
This form is for the District Court's use, to establish good cause to place outside the order of preference. This applies to foster care, guardianship and adoptive placements, as required by ICWA.
(Form #13 - 24kb rtf) (Form #13 - 9kb pdf)
Transfer Order
This form is for the District Court's use, when the court is granting a Tribe's or parent's request for transfer of jurisdiction to Tribal Court.
(Form #14 - 30kb rtf) (Form #14 - 10kb pdf)
Consent to Termination of Parental Rights and Certification - Adoption of an Indian Child
This is a form indicating consent to termination of parental rights of an Indian Child, when a birth parent voluntarily relinquishes parental rights. The form must be signed before a judge, and must certify items specified in 25 U.S.C. § 1913.
(Form #15 - 25kb rtf) (Form #15 - 10kb pdf)
Notice to the Secretary of the Interior or His/Her Designee of Final Decree or Order of Adoption of an Indian Child Pursuant to 25 U.S.C. § 1951
This form must be used when there has been a decree of adoption of an Indian Child, as notice to the Secretary of the Interior must be provided.
(Form #16 - 25kb rtf) (Form #16 - 6kb pdf)
Social Worker Checklist
This is checklist to be used by social workers. Section A1 should be used in ALL cases. If there is an indication that a child may be an Indian Child, the rest of the checklist should be completed.
(Form #17 - 42kb rtf) (Form #17 - 22kb pdf)
Face Sheet
This form is for the use of social workers. It is a helpful tool to document information regarding children in care.
(Form #18 - 64kb rtf) (Form #18 - 17kb pdf)
Legal Face Sheet and History
This form is for the use of social workers. It is a helpful tool for all cases, as it aids in the proper documentation of legal information.
(Form #19 - 28kb rtf) (Form #19 - 9kb pdf)
Placement Search
This form is for the use of social workers. This form is an important tool, as it documents search efforts made on behalf of the child. This form may be used for all children, but should certainly be used for Indian Children.
(Form #20 - 37kb rtf) (Form #20 - 8kb pdf)

Source: Indian Child Welfare Act: A Manual for North Dakota Practitioners (The manual was developed by a task force and produced by the N.D. Department of Human Services.)

Contact Information Concerning the Manual

N.D. Department of Human Services
Legal Advisory Unit
600 E Boulevard Ave
Bismarck ND 58505-0250
Phone: (701) 328-2311



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