ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address):

FOR COURT USE ONLY

ICWA-050

FAX NO. (Optional):

SUPERIOR COURT OF CALIFORNIA, COUNTY OF

TELEPHONE NO.:

E-MAIL ADDRESS (Optional):

ATTORNEY FOR (Name):

STREET ADDRESS:

MAILING ADDRESS:

CITY AND ZIP CODE:

BRANCH NAME:
CHILD'S NAME:

 NOTICE OF PETITION AND PETITION TO TRANSFER CASE 
INVOLVING AN INDIAN CHILD TO TRIBAL JURISDICTION

CASE NUMBER:

RELATED CASES (if any):

TO ALL PARTIES:

1. A hearing on this petition will be held as follows:

a.  Date:

Time:

Dept.:

Room:

b. Address of court:

same as noted above

other (specify):

2.   Child's name:                                                                                                                    Date of birth:

3.  

On behalf of the        

parent

Indian custodian

child's tribe, I ask the court to transfer jurisdiction over the

above named child's case to the jurisdiction of the tribe listed below:

Name of federally recognized tribe:

Name of tribal court or tribal administrative body:

Street address:

Mailing address of court:

City, state, and zip code:

Telephone:                                                                             Fax:

I declare under penalty of perjury under the laws of the State of California that the foregoing and all attachments are true and correct.

Date:

(TYPE OR PRINT NAME)

(SIGNATURE OF DECLARANT)

Form Approved for Optional Use 
Judicial Council of California
ICWA-050 [New January 1, 2008]

 NOTICE OF PETITION AND PETITION TO TRANSFER CASE 
INVOLVING AN INDIAN CHILD TO TRIBAL JURISDICTION

Page 1 of 3

Family Code, § 177(a);
Probate Code, § 1459.5(b);
Welfare and Institutions Code, § 305.5;
Cal. Rules of Court, rule 5.483
www.courtinfo.ca.gov

CHILD'S NAME:

CASE NUMBER:

ICWA-050

PROOF OF SERVICE

Notice of Petition and Petition to Transfer Case Involving an Indian Child to Tribal Jurisdiction ICWA-050 must be served on all other 
parties or attorneys for the parties. After getting a hearing date from the court clerk and completing the form, anyone at least 18 years 
of age EXCEPT A PARTY in this action may personally serve or mail the request. The person who serves the notice must fill out and 
sign the proof of service. This form may not be filed with the court until all the parties or their attorneys are served. A request to 
transfer cannot be heard for juvenile dependency cases until after the JV-100 or JV-110, Juvenile Dependency Petition has been filed, 
for juvenile delinquency cases not until after the jurisdiction hearing, and for probate cases not until after the jurisdictional hearing.

1.   At the time of service I was at least 18 years of age and not a party to the legal action.

2.   I served a copy of form ICWA-050 and all attachments as follows (check either a or b below for each person served):

a.

Personal service. I personally delivered a copy of form ICWA-050 and all attachments as follows:

(1)  Name of child's attorney (if applicable) served:

(2) Name of              parent (if self-represented) 
      or              parent's attorney (if applicable) served:

(a)  Address:

(a)  Address:

(b)  Date of delivery:
(c)  Time of delivery:

(3)  Name of Appointed Special
      Advocate (if applicable) served:

(a)  Address:

(5)   Name of              child's caregiver
       or              Indian custodian served:

(b)  Date of delivery:

(c)  Time of delivery:

(a)  Address:

(b)  Date of delivery:
(c)  Time of delivery: 

(a)  Address:

(b)  Date of delivery:
(c)  Time of delivery:

(7) Name of              parent (if self-represented) 
      or              parent's attorney (if applicable) served:

(4) Name of              social worker (dependency only)
      or              probation officer (delinquency only) 
      served:

(b)  Date of delivery:

(c)  Time of delivery:

(a)  Address:

(b)  Date of delivery:
(c)  Time of delivery:

(6)  Attorney for child welfare services agency 
      (dependency only) served:
      (a)  Address:

(b)  Date of delivery:
(c)  Time of delivery: 

(8)  District Attorney
      (delinquency only) served:
     

(a)  Address:

(b)  Date of delivery:
(c)  Time of delivery:

ICWA-050 [New January 1, 2008]

Page 2 of 3

 NOTICE OF PETITION AND PETITION TO TRANSFER CASE 
INVOLVING AN INDIAN CHILD TO TRIBAL JURISDICTION

CHILD'S NAME:

CASE NUMBER:

ICWA-050

b.

Mail. I deposited a copy of form ICWA-050 and all attachments in the United States mail, in a sealed envelope with 
postage fully prepaid, addressed as follows:

(1)  Name of child's attorney (if applicable) served:

(2) Name of              parent (if self-represented) 
      or              parent's attorney (if applicable) served:

(a)  Address:

(a)  Address:

(b)  Date of deposit: 
(c)  Place of deposit:

(3)  Name of Appointed Special
      Advocate (if applicable) served:

(a)  Address:

(b)  Date of deposit: 

(c)  Place of deposit: 

(5)   Name of              child's caregiver
       or              Indian custodian served:

(a)  Address:

(b)  Date of deposit: 
(c)  Place of deposit: 

(a)  Address:

(b)  Date of deposit: 
(c)  Place of deposit:

(7) Name of              parent (if self-represented) 
      or              parent's attorney (if applicable) served:

(b)  Date of deposit: 

(c)  Place of deposit: 

(4) Name of              social worker (dependency only)
      or              probation officer (delinquency only) 
      served:

(a)  Address:

(b)  Date of deposit: 
(c)  Place of deposit: 

(6)  Attorney for child welfare services agency 
      (dependency only) served:
      (a)  Address:

(b)  Date of deposit: 
(c)  Place of deposit: 

(8)  District Attorney 
      (delinquency only) served:
     

(a)  Address:

(b)  Date of deposit: 
(c)  Place of deposit: 

Attachment. If there are additional persons to serve, attach a separate piece of paper to form ICWA-050, write the 
child's name and case number on the top, and list additional persons' names, addresses, dates of delivery or deposit, 
times of delivery or deposit, and whether service was made personally or by mail.

I declare under penalty of perjury under the laws of the State of California that the foregoing and all attachments are true and correct.

c. 

Date:

(TYPE OR PRINT NAME)

(SIGNATURE OF PERSON WHO SERVED NOTICE)

ICWA-050 [New January 1, 2008]

 NOTICE OF PETITION AND PETITION TO TRANSFER CASE 
INVOLVING AN INDIAN CHILD TO TRIBAL JURISDICTION

Page 3 of 3