Title: IN THE CHANCERY COURT OF PIKE COUNTY, MISSISSIPPI
Author: County
Last saved by: Stacye Campbell
Company: Mississippi Supreme Court

IN THE CHANCERY COURT OF 			 COUNTY, MISSISSIPPI

													

								CAUSE NO. 				

AFFIDAVIT REGARDING THE INDIAN CHILD WELFARE ACT (ICWA)

STATE OF MISSISSIPPI

COUNTY OF 			

	COMES NOW 				, who being first duly sworn, states under oath the following:
1.	I am the 				 (state relationship to child) of 								 (name of child), the minor child whose custody and welfare is the subject of this action.
2.	One of the possible outcomes sought in this action is the placement of custody in a person other than one of the natural parents by either a permanent custody award, a long-term placement in foster-care, a termination of parental rights of the natural parents, or an adoption by persons other than one of the natural parents and a step-parent.
3.	The minor child is an unmarried minor under the age of eighteen years.
4.	The minor child  (	) is (	  )is not an enrolled member of any Indian tribe.
5.	The minor child (	) is (	  )is not eligible for membership in an Indian tribe and is the biological child of a member of an Indian tribe.
6.	Affiant asserts that the Indian Child Welfare Act (	  ) does (     ) does not  apply to these proceedings.
7.	If Affiant asserts that ICWA does apply to these proceedings, Affiant has given or will give written notice of these proceedings to the Indian tribe in which the child holds membership or is eligible for membership as follows: 																																			  (state name of tribe, the date of the notice, and the address used for notice, with a copy of the written notice attached)			
DATED this the 		 day of 				, 20		 .

	SWORN TO AND SUBSCRIBED before me, this the 		 day of 			, 20		.

													
							NOTARY PUBLIC

My commission expires: ___________________

Indian Child Welfare Act Affidavit		Page  of 

(Revised 12/2014)