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

FOR COURT USE ONLY

JV-419

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:

GUARDIANSHIP (JUVENILE)—CONSENT AND WAIVER OF RIGHTS

CASE NUMBER:

To the parent, legal guardian, Indian custodian, or authorized representative of the child's tribe: Read this form carefully. The 
judge will ask you if you understand your rights to family maintenance and reunification services, your right to a trial, and, if applicable, 
your rights under the Indian Child Welfare Act and whether you are voluntarily giving up those rights and consenting to the 
guardianship.

1.  a. 

  I am the child's   

mother     

 presumed father   

 Indian custodian   

 other (specify):

b.   

c.  

and I understand that I have the right to receive family maintenance services to help the child remain in my care and family 
reunification services to help me reunify with the child.

I am the child's biological father, and I understand that the court may order family maintenance services to help the child 
remain in my care and to receive family reunification services to help me reunify with the child.

I am the child's alleged father, and I understand that if I am judged to be the child's biological father, the court may order 
family maintenance services to help the child remain in my care and family reunification services to help me reunify with 
the child.

For items 2 through 8, initial the line for each item that applies. If you have a question, ask your attorney or the judge before you 
initial that item.                                                                                                                                                                             Initial

2.  The types of services that may be available have been explained to me. 

3.  I am not interested in receiving family maintenance services or family reunification services. 

4.  I believe that a guardianship with (name):
     is in the child's best interest, and I consent to his or her appointment as the guardian of the

 person    

 estate of the child.       

5.  I understand that by signing this document, I give up the following rights:

a.  The right to trial or hearing on the child's placement 
b.  The right to see and hear witnesses who testify 
c.  The right to cross-examine witnesses, including the author of any reports and the persons cited in the report 
d.  The right to testify on my own behalf and to present my own evidence and witnesses 
e.  The right to use the court's authority to compel witnesses to come to court and produce evidence 
f.   The right to assert any privilege against self-incrimination in this proceeding 
g.  The right to receive family maintenance services and family reunification services 

6.  

  Waiver of rights under the Indian Child Welfare Act (ICWA) (25 U.S.C. § 1901 et seq.)

a.  The child is an Indian child and I am
  the child's Indian mother.
  the child's Indian father.
  the child's Indian custodian.
  the authorized representative of the child's tribe.

(1)   
(2)  
(3) 
(4) 

Form Approved for Optional Use 
Judicial Council of California 
JV-419 [Rev. January 1, 2007]

GUARDIANSHIP (JUVENILE)—
CONSENT AND WAIVER OF RIGHTS

Page 1 of 2

Welfare and Institutions Code, § 360(a);
Cal. Rules of Court, rules 5.664, 5.695 
www.courtinfo.ca.gov

CHILD'S NAME:

CASE NUMBER:

JV-419

6.

b.    

  By signing this document, I understand that I have the following ICWA rights, which I am giving up:                    Initial

(1)  The right to request a transfer of the proceedings to the jurisdiction of the child's tribe
(2)  The right to intervene in the proceeding
(3)

The right to require a showing that active efforts were made to provide remedial services and rehabilitative 
programs designed to prevent the breakup of the Indian family and that these efforts have proven unsuccessful 
The right to require clear and convincing proof, including the testimony of qualified expert witnesses that 
continued custody of the child by the parent or Indian custodian is likely to result in serious emotional or 
physical damage to the child

(4)

(5)  The right to have the child placed according to the statutory preference 

7.    

This waiver of rights and consent to guardianship is given with the understanding that the individual named in 
item 4 will be appointed as the child's guardian. If that individual is not appointed or his or her status as the child's 
guardian is terminated, this waiver and consent is withdrawn and my right to a trial on the issue of the child's placement, 
my right to child welfare services, and any rights I may have under ICWA will be reinstated as they existed on the date 
this form was signed.  

8.   I have discussed my rights with my attorney, and I knowingly and intelligently waive those rights. 

Date:

Date:

Date:

(TYPE OR PRINT NAME)

(SIGNATURE)

DECLARATION OF INTERPRETER

9.   The   

mother
presumed father

biological father
alleged father

legal guardian
Indian custodian

authorized representative of the child's tribe
other (specify):

is unable to read or understand this form because his or her primary language is (specify):

10.

I declare under penalty of perjury and under the laws of the State of California that I have, to the best of my ability, read or 
translated this form for the person named on the signature line above who said he or she understood the form before signing it.

(TYPE OR PRINT NAME)

(SIGNATURE OF INTERPRETER)

DECLARATION OF ATTORNEY (Required)

11.  I am the attorney for   

mother
presumed father

biological father
alleged father

legal guardian
other (specify):

Indian custodian

  The rights under the Indian Child Welfare Act

and I have explained to him or her the following:
a.  
b.   The nature of family maintenance services and family reunification services
c.

d.
e.

The right to a trial, the right to assert the privilege against self-incrimination, the right to confront and cross-examine 
witnesses, the right to subpoena witnesses, and the right to present evidence on one's own behalf
The nature of a guardianship and his or her continuing rights and responsibilities if a guardian is appointed
That his or her waiver of rights and consent to guardianship will result in the appointment of the person named in item 
4 as the child's guardian. If that individual is not appointed or his or her status as the child's guardian is terminated, this 
waiver and consent will be withdrawn and the right to a trial on the issue of the child's placement, the right to receive 
family maintenance and reunification services, and any rights he or she may have under ICWA will be reinstated

12.  

I am satisfied that he or she understands and voluntarily waives those rights and consents to the establishment of the guardianship.

(cid:96)

(cid:96)

(cid:96)

(TYPE OR PRINT NAME)

(SIGNATURE OF ATTORNEY)

JV-419 [Rev. January 1, 2007]

Page 2 of 2

GUARDIANSHIP (JUVENILE)—
CONSENT AND WAIVER OF RIGHTS