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ICWA-101

Agreement of Parent or Indian Custodian 
to Temporary Custody of Indian Child

Clerk stamps date here when form is filed.

(This form must be signed after the judge has explained the terms and conditions  
of the consent as set out in items 6 and 7. A copy of this form shall be provided to the 
child's tribe in accordance with sections 224.2(e)(3), (f), and 361.31(g) of the Welfare and 
Institutions Code.)

I want the child to be temporarily placed in the custody of  
(Name(s) print or type):
a.

b.
Their relationship to Indian child (check all that apply):

Related to child (specify):
Member of child’s tribe
None of the above

Parent(s)

1

2

Fill in court name and street address:

Superior Court of California, County of

1

The placement in       complies with the placement preference 
requirements of the Indian Child Welfare Act and section 361.1 of the 
Welfare and Institutions Code because: (please check one):                      
a. The placement meets the placement preference requirements of the 

Indian Child Welfare Act because the placement is with:   

Case Number:

Court fills in case number when form is filed.

A member of the child's extended family;
A foster home licensed, approved, or specified by the child's tribe;
An Indian foster home;
Follows the order of preference established by the child's tribe; OR

b. By clear and convincing evidence there is good cause to deviate 

from the placement preferences based on:

The request of one or both of the Indian child's parents who attest that they have reviewed the placement  
options, if any, that comply with the order of preference;
By request of the child, if the child is of sufficient age and capacity to understand the decision that is being 
made;
The presence of a sibling attachment that can be maintained only through a particular placement;
The extraordinary physical, mental, or emotional needs of the Indian child; or
The unavailability of a suitable placement within the preferences; a diligent search was conducted. (If using 
this option, evidence of the diligent search must be contained in the record.)

Age:

3

Indian child (name):
Date of birth:
Child’s tribe(s):

Membership:

4 Your name:

Your address:

City:
Phone:

Check here if you do not know the membership number.

Parent

Indian Custodian (Check only one. Each must fill out a separate form.)

State:

Your tribe(s):

Zip:
Membership #:

Check here if you do not know the membership number.

Judicial Council of California,  
New January 1, 2021, Mandatory Form 
25 U.S.C. § 1913; 
Welfare and Institutions Code, § 16507.4(b)(3)

Agreement of Parent or Indian Custodian 
to Temporary Custody of Indian Child

ICWA-101, Page 1 of 3

Name of Parent or Indian custodian:

Your lawyer (if you have one): (Name, address, phone number, and State Bar number):

Case Number:

The proposed placement

will

will not be eligible for Aid to Families with Dependent Children.

5

6

I am the person in       and I say:

4

a. That I am presently unable to care for the child and prefer that the child be placed with the person(s) listed in     .1
b. I agree to the temporary custody of my child by the person(s) listed in      .1
c. No one has threatened me, including the threat of removing the child from my custody, or made promises to me 

to get me to sign this form. 
I understand that I can change my mind and that, if I do, the child will be returned to me by contacting

d.

(insert name of social worker of other individual to contact)

at
I do not give up any of my rights under the Indian Child Welfare Act by signing this form. 

e.
f. My child was at least 10 days old when I signed this form.

(insert contact information).

7 At the time of signing this form, neither I nor the child live or are domiciled on an Indian reservation of a tribe that 

exercises exclusive jurisdiction over child custody proceedings. 

Date:

Type or print your name

Signature of parent or Indian custodian

New January 1, 2021

Agreement of Parent or Indian Custodian 
to Temporary Custody of Indian Child

ICWA-101, Page 2 of 3

Name of Parent or Indian custodian:

Case Number:

Judge's Certification

I, Judge
Superior Court of California, County of

, certify:

• 
• 

• 

• 

• 

It has been at least 10 days since the child's birth;
I fully explained the terms and consequences of consenting and entering into this agreement in detail;

If this is a voluntary out-of-home placement pursuant to section 16507.4 of the Welfare and Institutions Code, I have 
reviewed the written agreement between the county welfare department and the parent or Indian custodian and the 
SOC-155C form if any and fully explained the terms and consequences of those to the parent or Indian custodian, and 
they were fully understood by the parent or Indian custodian;

I have explained to the parent or Indian custodian that they may withdraw their consent for any reason and at any time 
by contacting the person identified in      d. above;

6

I have reviewed how the placement meets the placement preference requirements of the Indian Child Welfare Act and 
section 361.31 of the Welfare and Institutions Code and

the placement meets the placement preferences or

there is good cause to deviate from the placement preferences.

•  After the terms and consequences as set out above were fully explained in detail to the parent or Indian custodian in 
English or after they were interpreted into a language that they understood, the terms and consequences were fully 
understood by the parent or Indian custodian and the document was executed and recorded before me. 

Certified:

Date:

Print or type name of Judge (or Judicial Officer)

Judge (or Judicial Officer)

New January 1, 2021

Agreement of Parent or Indian Custodian 
to Temporary Custody of Indian Child

ICWA-101, Page 3 of 3

Agreement of Parent or Indian Custodian to Temporary Custody of Indian Child

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the California state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from selfhelp.courts.ca.gov (2023-03)
Page(s): 3
Fields(s): 52
Average fields per page: 17
Reading Level: Grade 8
LIST Grouping(s): Unknown

Use our Rate My PDF tool to learn more. Go beyond the above insights and learn more about this or any pdf form at RateMyPDF.com, includes: counts of difficult words used, passive voice decetion, and suggestions for how to make the form more usable.

Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

Here are the fields we could identify.

page_right_caption_court_info was ICWA-101[0].Page1[0].RightCaption[0].CourtInfo_ft[0] (0.58 conf)
page_right_caption_case_number was ICWA-101[0].Page1[0].RightCaption[0].CaseNumber_ft[0] (0.34 conf)
page_list_protected_full_name_ft__1 was ICWA-101[0].Page1[0].List1[0].Li1[0].ProtectedFullName1_ft[0] (0.33 conf)
page_list_protected_full_name_ft__2 was ICWA-101[0].Page1[0].List1[0].Li2[0].ProtectedFullName2_ft[0] (0.33 conf)
icw_page_list_li_group_check_box was ICWA-101[0].Page1[0].List1[0].Li3[0].Group1[0].CheckBox1[0] (0.36 conf)
icw_page_list_li_group_text_field was ICWA-101[0].Page1[0].List1[0].Li3[0].Group1[0].TextField1[0] (0.38 conf)
icw_page_list_li_check_box__1 was ICWA-101[0].Page1[0].List1[0].Li3[0].CheckBox2[0] (0.35 conf)
icw_page_list_li_check_box__2 was ICWA-101[0].Page1[0].List1[0].Li3[0].CheckBox3[0] (0.35 conf)
icw_page_list_li_check_box__3 was ICWA-101[0].Page1[0].List1[0].Li3[0].CheckBox4[0] (0.35 conf)
icw_page_list_li_meet_cb__1 was ICWA-101[0].Page1[0].List2[0].Li1[0].meet_cb[0] (0.36 conf)
icw_page_list_li_meet_cb__2 was ICWA-101[0].Page1[0].List2[0].Li1[0].meet_cb[1] (0.36 conf)
icw_page_list_li_meet_cb__3 was ICWA-101[0].Page1[0].List2[0].Li1[0].meet_cb[2] (0.36 conf)
icw_page_list_li_meet_cb__4 was ICWA-101[0].Page1[0].List2[0].Li1[0].meet_cb[3] (0.36 conf)
icw_page_list_li_meet_cb__5 was ICWA-101[0].Page1[0].List2[0].Li2[0].meet_cb[0] (0.36 conf)
icw_page_list_li_meet_cb__6 was ICWA-101[0].Page1[0].List2[0].Li2[0].meet_cb[1] (0.36 conf)
icw_page_list_li_meet_cb__7 was ICWA-101[0].Page1[0].List2[0].Li2[0].meet_cb[2] (0.36 conf)
icw_page_list_li_meet_cb__8 was ICWA-101[0].Page1[0].List2[0].Li2[0].meet_cb[3] (0.36 conf)
icw_page_list_li_meet_cb__9 was ICWA-101[0].Page1[0].List2[0].Li2[0].meet_cb[4] (0.36 conf)
icw_page_list_li_child_ft was ICWA-101[0].Page1[0].List3[0].Li1[0].child_ft[0] (0.36 conf)
icw_page_list_li_date_birth_dt was ICWA-101[0].Page1[0].List3[0].Li1[0].DateBirth_dt[0] (0.34 conf)
icw_page_list_li_age was ICWA-101[0].Page1[0].List3[0].Li1[0].Age[0] (0.38 conf)
icw_page_list_li_tribe__1 was ICWA-101[0].Page1[0].List3[0].Li1[0].tribe[0] (0.36 conf)
icw_page_list_li_member__1 was ICWA-101[0].Page1[0].List3[0].Li1[0].member[0] (0.36 conf)
icw_page_list_li_check_box__4 was ICWA-101[0].Page1[0].List3[0].Li1[0].CheckBox5[0] (0.35 conf)
page_list_li_full_name_ft__1 was ICWA-101[0].Page1[0].List4[0].Li1[0].FullName_ft[0] (0.37 conf)
icw_page_list_li_cb__1 was ICWA-101[0].Page1[0].List4[0].Li1[0].you_cb[0] (0.36 conf)
icw_page_list_li_cb__2 was ICWA-101[0].Page1[0].List4[0].Li1[0].you_cb[1] (0.36 conf)
icw_page_list_li_address was ICWA-101[0].Page1[0].List4[0].Li1[0].address[0] (0.36 conf)
icw_page_list_li_city was ICWA-101[0].Page1[0].List4[0].Li1[0].city[0] (0.36 conf)
icw_page_list_li_state was ICWA-101[0].Page1[0].List4[0].Li1[0].state[0] (0.36 conf)
icw_page_list_li_zip was ICWA-101[0].Page1[0].List4[0].Li1[0].zip[0] (0.36 conf)
icw_page_list_li_phone was ICWA-101[0].Page1[0].List4[0].Li1[0].phone[0] (0.36 conf)
icw_page_list_li_tribe__2 was ICWA-101[0].Page1[0].List4[0].Li1[0].tribe[0] (0.36 conf)
icw_page_list_li_member__2 was ICWA-101[0].Page1[0].List4[0].Li1[0].member[0] (0.36 conf)
icw_page_list_li_check_box__5 was ICWA-101[0].Page1[0].List4[0].Li1[0].CheckBox6[0] (0.35 conf)
page_px_caption_full_name_ft__1 was ICWA-101[0].Page2[0].PxCaption[0].FullName_ft[0] (0.32 conf)
icw_page_px_caption_case_number_ft__1 was ICWA-101[0].Page2[0].PxCaption[0].CaseNumber_ft[0] (0.33 conf)
icw_page_list_li_lawyer was ICWA-101[0].Page2[0].List4[0].Li2[0].lawyer[0] (0.36 conf)
icw_page_list_li_cb__3 was ICWA-101[0].Page2[0].List5[0].Li1[0].will_cb[0] (0.36 conf)
icw_page_list_li_cb__4 was ICWA-101[0].Page2[0].List5[0].Li1[0].will_cb[1] (0.36 conf)
page_list_li_name_contact_ft was ICWA-101[0].Page2[0].List6[0].Li4[0].NameContact_ft[0] (0.40 conf)
icw_page_list_li_contact_ft was ICWA-101[0].Page2[0].List6[0].Li4[0].contact_ft[0] (0.36 conf)
page_list_li_party_signature_dt__1 was ICWA-101[0].Page2[0].List7[0].Li1[0].PartySignature_dt[0] (0.36 conf)
page_list_li_full_name_ft__2 was ICWA-101[0].Page2[0].List7[0].Li1[0].FullName_ft[0] (0.37 conf)
page_px_caption_full_name_ft__2 was ICWA-101[0].Page3[0].PxCaption[0].FullName_ft[0] (0.32 conf)
icw_page_px_caption_case_number_ft__2 was ICWA-101[0].Page3[0].PxCaption[0].CaseNumber_ft[0] (0.33 conf)
icw_page_list_text was ICWA-101[0].Page3[0].List8[0].Text1[0] (0.36 conf)
page_list_li_party_signature_dt__2 was ICWA-101[0].Page3[0].List8[0].Li7[0].PartySignature_dt[0] (0.36 conf)
icw_page_list_li_text_field was ICWA-101[0].Page3[0].List8[0].Li7[0].TextField[0] (0.34 conf)
icw_page_list_li_code_cb__1 was ICWA-101[0].Page3[0].List8[0].Li5[0].code_cb[0] (0.36 conf)
icw_page_list_li_code_cb__2 was ICWA-101[0].Page3[0].List8[0].Li5[0].code_cb[1] (0.36 conf)
icw_page_list_drop was ICWA-101[0].Page3[0].List8[0].DropDownList1[0] (0.37 conf)

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The Legal Innovation & Technology Lab's Form Explorer Beta @ Suffolk Law School Last updated 2023-04-02

Agreement of Parent or Indian Custodian to Temporary Custody of Indian Child

About This Form:

Identified Data Fields:

Create an Interactive Version of this Form:

The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02