In the matter of 

First and last name of child

TO:              

(Name and telephone no. of natural 
parent or Indian custodian. State if 
unknown.)  

(Name and telephone no. of natural 
parent or Indian custodian. State if 
unknown.) 

(Name and telephone no. of ICWA 
Designated Tribal Agent. See list 
here. State if unknown.) 

(Use only if identity of parents, 
custodian, or tribe is unknown.
If grandparent(s) are known, please
attach a sheet with name(s) and 
date(s) of birth.)

 

 

Bureau of Indian Affairs, Midwest Regional Office
Norman Pointe II
5600 West American Blvd., Suite 500
Bloomington, MN 55437
(612) 725-4571 or 4572

 

 petition for adoption 

 petition for direct placement adoption 

right to petition the court to have this case transferred to the tribal court of the 

TAKE NOTICE:
 
1. A  
2. A copy of the petition is attached to this notice.
3. You have the absolute right to intervene in this proceeding and, absent objection by either Indian parent, you have the 
 
  Tribe. The tribal court may decline the transfer.
4. You may object to a transfer of this case to the tribal court.
5. As a parent or Indian custodian, you have the right to a court-appointed attorney if you are determined indigent. If you 
 
6. All parties notified shall keep confidential the information contained in this notice concerning this particular proceeding. 
  This notice shall not be handled by anyone not needing the information contained in the notice in order to exercise the 
 

intend to request a court-appointed attorney, you should contact the court immediately by telephone or in writing.

tribe’s rights under the Indian Child Welfare Act and the Michigan Indian Family Preservation Act.

  has been filed.

 

If you require accommodations to use the court because of a disability or if you require a foreign language interpreter to help 
you fully participate in court proceedings, please contact the court immediately to make arrangements.

USE NOTE: This notice must be sent to the parties by registered mail, return receipt requested.

Approved, SCAO
Form PCA 352, Rev. 3/23
MCL 712B.9, MCL 712B.27, 25 USC 1912, MCR 3.802(A)(3)
Page 1 of 1

Distribute form to: 
Court 
Copies as needed

STATE OF MICHIGANJUDICIAL CIRCUIT - FAMILY DIVISIONCOUNTYNOTICE OF ADOPTION PROCEEDINGSCONCERNING AN INDIAN CHILDCASE NO. and JUDGECourt addressCourt telephone no.JIS Code: NCI