I/We have received information about the Adoption Assistance Program, the Regional Center, mental health
services available through Medi-Cal or other programs, and federal and state tax credits that might be available.
If this is an agency adoption:
Child may have Indian ancestry:
Names of birth parents, if known:
Is the child a dependent of the court?
(If yes, fill out below):
Juvenile case number:
Whether you answered “Yes” or “No,” you must fill out and attach Indian Child Inquiry Attachment (form
ICWA-010(A)) and Parental Notification of Indian Status (form ICWA-020) or other proof that ICWA inquiry
has been completed in accordance with rule 5.481(a).
If you answered “Yes,” you must also fill out and attach Adoption of Indian Child (form ADOPT-220) if, after
notice, it is determined that ICWA does apply to the child.
Does the child have a legal guardian?
(If yes, attach a copy of the Letters of Guardianship and fill out below):
Date guardianship ordered:
ADOPT-200, Page 2 of 5
Child’s name before adoption (Fill out ONLY if this is an independent, stepparent, or tribal customary adoption):
Information about the child:
Place of birth (if known):
Date of birth:
If the child is 12 or older, does the child agree to
Child’s address (if different from yours):
The child’s new name will be:
Date child was placed in your physical care:
All persons with parental rights agree that the child should be placed for adoption by the California Department
of Social Services or a county adoption agency or a licensed adoption agency (Fam. Code, § 8700) and have
signed a relinquishment form approved by the California Department of Social Services, and the time to revoke
the relinquishment has expired or been waived.
(If no, list the name and relationship to child of each person who has not signed the
relinquishment form or whose time to revoke the relinquishment has not expired or been waived):
Revised January 1, 2014