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M   NOTICETOPARENTORPERSONINLOCOPARENTIS: Thisisanimportantlegal   documentandbysigningityouarepermanentlygivingupallcustodyandotherparental  rightstothechildnamedherein.Youaretoreceiveacopyofthisdocument.  5   I,򀀀C&%XCX(Name)#CXX%C&#Ԁ󀀀,(mother,father,IndianCustodian)of򀀀(Childsname) k Ѐ,aminorchild,state:  1.  ThechildwasbornonC&%XCXԀ(Dateofbirth)#CXX%C& #at򀀀C&%XCX(Placeofbirth)#CXX%C&} #Ԁat򀀀: OXXXCX0 #CXXXOX #Ԁa.m. OXXXCX0 #CXXXOXQ #Ԁp.m. D 2.  Iresideat򀀀,Countyof򀀀andStateof򀀀. ~ 3.  Iamoftheageof򀀀yearsandwasbornon򀀀.  , ! ! B(5h83m"o3"  o3 25h  4  .3  0    Iamamemberofthe________________TribeoftheStateof______________andmy "b enrollmentnumberis_________________.Mychildisamemberoforeligiblefor $} membershipwiththe_________________TribeoftheStateof_______________andthe  % childsenrollmentnumberis_______________.(Ifknownandapplicable.)o3 ݌;&(#(# Ќ  "o3"  o325h  5  .3  0    IdesiretorelinquishmyparentalrightstothechildandIdoherebyrelinquishthechildto q(! ЀC&%XCX(Nameofagency)#CXX%C&#Ԁ󀀀,whichIunderstandwillhavefullpowerandallthe )#  rightsofabirthparentorlegalguardianoverthechild,includingthepowertoplacethechild *$! foradoptionandgiveconsentthereto.o3݌+:%"(#(# } }8%%d%%d8{~ }  ь  "o3"  o3 25h  6  .3  0    I OXXXCX0 #CXXXOX#Ԁ do OXXXCX0 #CXXXOX#Ԁ donot requestthattheplacementpreferencesoftheIndianChildWelfareActare  followed,andIpreferthatmychildbeplacedwith򀀀(Statenameandrelationship.)󀀀  Ѐ.o3 :݌:(#(# Ќ  "o3"  o325h  7  .3  0    Iwishto,andIunderstandthatbysigningthisrelinquishmentIdo,permanentlygiveupall  p custodyandotherparentalrightsIhavetosuchchild,includingtherighttoreceivenotice   ofanysubsequentadoptionproceedingsinvolvingthechild.o3݌. (#(# Ќ  "o3"  o325h  8  .3  0    Iunderstandthatuntilthecourtentersafinalorderofadoption,Imaywithdrawmyconsent d andmayregaincustodyofmychild.o3݌ (#(# Ќ  "o3"  o325h  9  .3  0    IunderstandIhavetherighttobenotifiedwhenthefinaldecreeofadoptionisgranted,set -  asideorvacated. OXXXCX0 #CXXXOX#ԀI donot wanttobenotified. OXXXCX0 #CXXXOX#ԀI do wanttobenotifiedandunderstand H  Imustkeepthecourtinformedofmyaddresssothecourtmayfindme.o31݌g (#(# Ќ  "o3 "  o325h  10  .3  0    Ifullyunderstandtheconsequencesofmyactionsandnothreatsorpromiseshavebeenmade % toinducemetosignthisconsent.o3݌@(#(# Ќ  "o3 "  o325h  11  .3  0    Thechildnamedabovewasborntomemorethanten(10)daysbeforemysigningthis v relinquishment.o3%݌ (#(# Ќ  "o3 "  o3:25h  12  .3  0    IacknowledgethatatthetimeofthesigningofthisrelinquishmentIamnotdomiciledon ? orresidinguponanyIndianreservation.o3:g݌Z(#(# Ќ  "o3 "  o325h  13  .3  0    IcanreadandunderstandEnglish.IhavereadandIunderstandtheaboveandIamsigning ! itasmyfreeandvoluntaryact.o3݌3"(#(# Ќ  Dated򀀀,at򀀀: OXXXCX0 #CXXXOX=!#Ԁa.m. OXXXCX0 #CXXXOX!#Ԁp.m.0 p ""J"_pp2 @"  @"  @"  @"  @"  @" i$p(#p(#       z  p SignatureofParent/IndianCustodian %         CERTIFICATEOFATTORNEYFORRELINQUISHINGMINORPARENT  (Q"     Iamalicensedattorneyrepresenting򀀀.Ihavefully +$! explainedthatbysigningthisrelinquishment򀀀ispermanently *,%" givingupallparentalrightstothechildand(she)(he)hasstatedthatsuchis(her)(his)intentionand = desire.Iwaspresentattheexecutionofthisrelinquishment. X ? z p(# z p"(#?Date:򀀀 z 0 p C&%XCXԀ Qp(#p(# 0  0(#(#0 (#(#0z (# (#0pz (#z (#SignatureofAttorney lp(#p(#       z  p #CXX%C&&#_S.Ct_.#_______________  o   e(Mustbeacknowledgedbeforeajudge.)   @ ACKNOWLEDGMENTBEFOREJUDGEOFDISTRICTCOURT  N  ? z hp(# z p ?STATEOFKANSAS0 z 0hz (#z (#)G h(#h(#       z  h )ss: b COUNTYOF򀀀) }   I,򀀀,JudgeoftheDistrictCourt,򀀀Judicial  District,herebycertifythat򀀀,knowntometobethe   samepersonwhosenameissubscribedtotheforegoingrelinquishment,appearedbeforemethisday & inpersonand% E %E+acknowledgedthat(she)(he)signedsuchrelinquishmentas(her)(his)freeand A voluntaryact,forthespecifiedpurpose. \    IcertifythattheParent(IndianCustodian)understandsEnglishandIhavefullyexplained U thatbysigningsuchrelinquishment(she)(he)ispermanentlygivingupallparentalrightstosuch  p childand(she)(he)hasstatedthat(she)(he)understoodtheconsequenceandthatpermanent ! relinquishmentofparentalrightsis(her)(his)intentionanddesire. "  Dated______________,at____:____ OXXXCX0 #CXXXOXj.#Ԁa.m. OXXXCX0 #CXXXOX.#Ԁp.m. p  %       z  h  p  8&       z  h  p JudgeoftheDistrictCourt S'!     @  ACCEPTANCEOFCHILDBYAGENCY  *g$!    I,򀀀,theundersigned,onbehalfofC&%XCX(Nameofagency)#CXX%C&1#Ԁ, ,&# doherebyacceptcustodyof______________________,% G %G1theaboverelinquishedminorchild. -'$ Date:򀀀 z  h  X       z  h  p C&%XCXԀ#CXX%C&2# s6       z  h  p Signature v 9       z  h  p 򀀀  T 0  0(#(#0 (#(#0z (# (#0hz (#z (#0ph(#h(#Title  o  @p  @p  @p  @p  @p  p(#p(#            z  h  p @* XXXCX@jj&Authority } K.S.A.382203,382268and25U.S.C.1901etseq.  @$NotesonUse A   Withtheconsentoftheguardianadlitemandthesecretary,aparentmayrelinquishparental w: rights.Therelinquishmentshallbeacknowledgedbeforeajudge,anditshallbethedutyofthecourt U toadvisetherelinquishingparentoftheconsequencesoftherelinquishment.Ifaparentrelinquishes  p achildtothesecretarybasedonabeliefthattheotherparentwouldrelinquishthechildorbefound ! unfit,andneitheroccurs,therightsoftheparentwhorelinquishedbasedonthatbeliefshallnotbe " therebyterminated. #   Leavethoseitemsblank,ordeletethoseitems,thatdonotapplyinthecaseathand. %   _ICWA_Ԁrequiresthattherelinquishmentcertificationbythejudgeincludethestatement#CXXXX5#@XXXCXthat 4& theparentfullyunderstoodtheexplanationinEnglishorthatitwasinterpretedintoalanguagethat O'! theparentunderstood.25U.S.C.1913(a).Anyconsentgivenpriorto,orwithintendaysafter,birth j(-" oftheIndianchildshallnotbevalid.#CXXX@Xw:#XXXCX )H#    Because_ICWA_Ԁisinvokedthroughthestatusofthechild,anonIndianparentreceivesthe *c$! rightsaccordedby_ICWA_.ThisistherelinquishmentformthatbothanIndianandanonIndian +~%" parentofanIndianchildshoulduse.Thosesectionswhichareinapplicable,specificallyportions ,&# ofparagraph4,maybeleftblank. -'$ z z8%%d%%d8x{ z    _ICWA_Ԁalsoprovidesprotectionforan IndianCustodiandefinedat25U.S.C.1903(6)as =  anyIndianpersonwhohaslegalcustodyofanIndianchildundertriballaworcustomorunder X Statelawortowhomtemporaryphysicalcare,custody,andcontrol,hasbeentransferredbythe s6 parentofsuchchild.TherightsofanIndianCustodianareanalogoustoparentalrightsandmust  Q beterminatedwiththesameformality.  l   RelinquishmentofanIndianchildmayberevokedatanytimepriortoissuanceofthefinal   decreeofadoption.25U.S.C._1913._     Theplacementpreferencessetoutin_ICWA_Ԁarebindingabsentgoodcausetothecontrary.   TheBIAguidelinesincludeparentalpreferenceasanexampleofgoodcausealongwith  extraordinaryneedsofthechildasestablishedbyaqualifiedexpertwitness;andtheunavailability 0  ofsuitablefamiliesmeetingthepreferencecriteriaafteradiligentsearch. K    #CXXXX;#_ICWA_,at25_USC_Ԁ1913_(c)_,provides Inanyvoluntaryproceedingforterminationofparental f)  rightsto,oradoptiveplacementof,anIndianchild,theconsentoftheparentmaybewithdrawnfor D  anyreasonatanytimepriortotheentryofafinaldecreeofterminationoradoption,asthecasemay _  be,....SeeMatterof_Kiogma_,472N.W.2d13,cert.denied,112_S.Ct_.952(1992);_B.R.T._Ԁv. z ExecutiveDirector,391N.W.2d594(N.D.1986);Matterof_J.R.S._,690P.2d10(Alaska1984).  XXXCX  Voluntaryrelinquishmentofparentalrightsandacceptancebyanadoptionagencyterminates  parentalrightsandobligations,includingtheobligationtopaychildsupport.Secretaryof_SRS_Ԁv.  Clear,248_Kan_.109,804P.2d961(1991).However,adecreeofadoptiondoesnotrelieveaparent # ofhisorherobligationtopaythechildsupportdueandowingatthetimeoftheadoption.Child > support_arrearages_Ԁwhichhavebeenreducedtojudgmentarenotextinguishedorcanceledby Y terminationofparentalrights._Michels_Ԁv._Weingartner_,254_Kan_.44,864P.2d1189(1993). t7   Therelinquishmentofachildtoanagencyforadoptionmustbeacceptedinwritingbythat R agencyinordertobeeffective.InreBabyBoyN.,19_Kan.App_.2d574,874P.2d680(1994) m (construingK.S.A.592124(a)whichissubstantiallysimilartoK.S.A.382268).#CXXXXF#     IfthepersoncannotreadandunderstandEnglish,specificallystatehowtheywereinformed ! ofalltheirrightsandtheconsequencesofrelinquishment. p  "      @*