ࡱ                >  	               z          |          y    '`	               I   bjbj                  	 8n                                                                                                                              t      t      t  8     L              O"       &                                        z!     |!      |!      |!      |!      |!      |!  $   ;#  h  %  H   !  i                         @                                  @      @      !                                              	"                       @  X                           z!                                                                    @      z!                                                                                                                       P7$        t        X                 V  $  "  0   O"            %          %                                                                                    %                      x   @      @            @      @                                      @      @      @      !      !                                        X                                   @      @      @      O"      @      @      @      @                                                                                                                 	"                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         MISSOURI DEPARTMENT OF SOCIAL SERVICESCHILDRENS DIVISIONIndian Ancestry QuestionnaireThe information requested below is necessary to determine whether the Indian Child Welfare Act (25 U.S.C. 1901 et seq.) applies to your child/ren.  This law provides legal protections designed to prevent the breakup of Indian families, and may provide important rights and benefits to you and your child/ren. Please give us as much of the requested information as possible, even if you are unsure if you, your child, or t h e   c h i l d  s   o t h e r   p a r e n t   a r e   e n t i t l e d   t o   m e m b e r s h i p   i n   a   t r i b e .      1 .   Y o u r   n a m e :  	    F O R M T E X T           	    2 .     R e l a t i o n s h i p   t o   C h i l d :       F O R M T E X T              3 .     N a m e   o f   c h i l d :    1 .      F O R M T E X T              2 .      F O R M T E X T              3 .      F O R M T E X T              4 .      F O R M T E X T              5 .      F O R M T E X T              4 .     C h e c k   o n e :     F O R M C H E C K B O X       I   h a v e   n o   i n f o r m a t i o n   r e g a r d i n g   a n y   I n d i a n   a n c e s t r y   o f   t h e   c h i l d / c h i l d r e n   l i s t e d   o n   t h i s   f o r m .     ( I f   y o u   h a v e   n o   s u c h   i n f o r m a t i o n ,   y o u   m a y   s k i p   q u e s t i o n s   5      9 .     P l e a s e   s i g n   a n d   d a te at bottom of form).  FORMCHECKBOX  Yes, I have information or belief that the child/children has Indian Ancestry. 5.  If you answered YES to question 4, please describe any known Indian ancestry of the child/children.  If you know the name(s) of any tribe(s) in which the child/children, their parents or grandparents may have membership, please provide as much information as you can, including which side of the family has Indian ancestry.  If you need more space, feel free to attach additional pag e s .        F O R M T E X T              6 .     N a m e   o f   t r i b e   o r   t r i b e s :       F O R M T E X T              7 .     M a n y   t r i b e s   u s e   b o t h   t r a d i t i o n a l   a n d   o f f i c i a l   n a m e s .     I f   y o u   k n o w   a n y   a d d i t i o n a l   n a m e s   t h a t   t h e   c h i l d / c h i l d r e n  s   t r i b e ( s )   m a y   b e   k n o w n   b y ,   p l e a s e   p r o v i d e   t h i s   i n f o r m a t i o n :       F O R M T E X T              8 .     I f   d i f f e r e n t   f r o m   n a m e   o f   t r i b e ,   p l e a s e   l i s t   n a m e   o f   r e s e r v a t i o n ,   R a n c h e r i a ,   p u e b l o ,   o r   A l a s k a n   N a t i v e   v i l l a g e ,   i f   k n o w n   ( i f   m o r e   t h a n   o n e ,   p l e a s e   l i s t   a l l ) .     I f   t h i s   i n f o r m a t i o n   d o e s   n o t   a p p l y   t o   a l l   c h i l d r e n   l i s t e d ,   p l e a s e   s t a t e   a s   t o   w h i c h   c h i l d   i t   a p p l i e s .     P l e a s e   f e e l   f r e e   t o   a t t a c h   a d d i t i o n a l   p a g e s   i f   n e c e s s a r y .      F O R M T E X T              9 .     I f   y o u   h a v e   i n f o r m a t i o n   t h a t   t h e   c h i l d / c h i l d r e n ,   e i t h e r   p a r e n t   o r   a n y   g r a n d p a r e n t   i s   a n   e n r o l l e d   m e m b e r   o f   a n y   t r i b e ,   p l e a s e   s t a t e   w h o   i s      =  Z  \  	  	  2
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t  0                              P+  l                         4   4 
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t  0                                6                            4   4 
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t  0                                6                            4   4 
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t  0                                6                            4   4 
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t  0                                6                            4   4 
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t  0                                6                            4   4 
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t  0                                6                            4   4 
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      TC  VC  C  C                                                                                                                                                                                                                                                              j  kd-  $$If   l              * +                
t  0                                6                4   4 
l a  ytFx   $If         e n r o l l e d ;   t h e i r   r e l a t i o n s h i p   t o   t h e   c h i l d / c h i l d r e n ;   w h i c h   t r i b e ;   a n d   p r o v i d e   e n r o l l m e n t   n u m b e r   i f   y o u   k n o w   i t .     I f   y o u   n e e d   m o r e   s p a c e ,   p l e a s e   a t t a c h   a d d i t i o n a l   p a g e s .     ( A )   N a m e :      F O R M T E X T            R e l a t i o n s h i p   t o   c h i l d / c h i l d r e n :      F O R M T E X T                         T r i b e :      F O R M T E X T            E n r o l l m e n t   N u m b e r :      F O R M T E X T               ( B )   N a m e :      F O R M T E X T            R e l a t i o n s h i p   t o   c h i l d / c h i l d r e n :      F O R M T E X T                         T r i b e :        F O R M T E X T            E n r o l l m e n t   N u m b e r :      F O R M T E X T               ( C )   N a m e :      F O R M T E X T            R e l a t i o n s h i p   t o   c h i l d / c h i l d r e n :      F O R M T E X T                         T r i b e :      F O R M T E X T            E n r o l l m e n t   N u m b e r :      F O R M T E X T                 ( D )   N a m e :      F O R M T E X T            R e l a t i o n s h i p   t o   c h i l d / c h i l d r e n :      F O R M T E X T                           T r i b e :      F O R M T E X T            E n r o l l m e n t   N u m b e r :      F O R M T E X T                C E R T I F I C A T I O N  I   h a v e   a n s w e r e d   t h i s   q u e s t i o n n a i r e   t o   t h e   b e s t   o f   m y   k n o w l e d g e   a n d   b e l i e v e   t h e   a n s w e r s   a r e   t r u e .      F O R M T E X T               F O R M T E X T             S i g n a t u r e  D a t e                  C D - 1 1 6   0 3 / 0 9                                     C  C  >D  D              {            {                                                                                                                                                                                                             $If    }  kd.  $$If   l             0 *                                  
t  0                                6                            4   4 
l a  yt>
  ,D  .D  0D  :D  <D  bD  dD  fD  zD  |D  ~D  D  D  D  D  D  D  D  D  D  D  E  E  $E  &E  (E  2E  4E  6E  8E  TE  VE  jE  lE  nE  xE  zE  |E  E  E  E  ޮޮ޹ޮx޹ޮfޮ#j2  hrx, hFx CJ UaJ #jC1  hrx, hFx CJ UaJ #j0  hrx, hFx CJ UaJ #j/  hrx, hFx CJ UaJ hrx, hrx, CJ aJ  hrx, CJ aJ  h>
 CJ aJ  (j    hrx, hrx, CJ UaJ mH nH u j    hrx, hrx, CJ UaJ #j;/  hrx, hFx CJ UaJ  (D  D  D              {                                                                                                                                                                                                                              $If    }  kd'0  $$If   l             0 *                                  
t  0                                6                            4   4 
l a  yt>
  D  D  D  6E                                                                                                                                                                                                                                                                             $If    j  kd~0  $$If   l              * +                
t  0                                6                4   4 
l a  ytFx  6E  8E  |E  E              {            {                                                                                                                                                                                                             $If    }  kd1  $$If   l             0 *                                  
t  0                                6                            4   4 
l a  yt>
  E  E  E  E  E  E  E  E  E  E  E  F  
F  F  LF  NF  bF  dF  fF  pF  rF  tF  vF  F  F  F  F  F  F  F  F  F  F  F  F  F  G  G  G  "G  $G  ޮޮ޹ޮxޮf#j[5  hrx, hFx CJ UaJ #j4  hrx, hFx CJ UaJ #j4  hrx, hFx CJ UaJ #j3  hrx, hFx CJ UaJ hrx, hrx, CJ aJ  hrx, CJ aJ  h>
 CJ aJ  (j    hrx, hrx, CJ UaJ mH nH u j    hrx, hrx, CJ UaJ #j2  hrx, hFx CJ UaJ  (E  E  E              {                                                                                                                                                                                                                              $If    }  kd2  $$If   l             0 *                                  
t  0                                6                            4   4 
l a  yt>
  E  E  F  tF                                                                                                                                                                                                                                                                             $If    j  kdS3  $$If   l              * +                
t  0                                6                4   4 
l a  ytFx  tF  vF  F  G              {            {                                                                                                                                                                                                             $If    }  kd4  $$If   l             0 *                                  
t  0                                6                            4   4 
l a  yt>
  G  G  
G              {                                                                                                                                                                                                                              $If    }  kd5  $$If   l             0 *                                  
t  0                                6                            4   4 
l a  yt>
  
G  G  JG  G                                                                                                                                                                                                                                                                             $If    j  kd(6  $$If   l              * +                
t  0                                6                4   4 
l a  ytFx  $G  8G  :G  <G  FG  HG  G  G  G  G  G  G  G  G  G  G  G  G  G  G  H   H  4H  6H  8H  BH  DH  HH  JH  NH  hH  jH  .I  0I  ԿԷԿԷԿԷԿԷyrnj[             j    h r h r CJ  UaJ  h"e  hrx,  h"e h"e  h>
 CJ aJ  #j08  hrx, hFx CJ UaJ #j7  hrx, hFx CJ UaJ #j6  hrx, hFx CJ UaJ hrx, CJ aJ  (j    hrx, hrx, CJ UaJ mH nH u j    hrx, hrx, CJ UaJ #jw6  hrx, hFx CJ UaJ hrx, hrx, CJ aJ !G  G  G  FH              {            {                                                                                                                                                                                                             $If    }  kdc7  $$If   l             0 *                                  
t  0                                6                            4   4 
l a  yt>
  FH  HH  JH  LH  NH  jH  ,I  .I  VI  ~I                                                  w            w            w            n            n                                                                           	  $If   gd"e    $a$gd"e     }  kd8  $$If   l             0 *                                  
t  0                                6                            4   4 
l a  yt>
  	0I  DI  FI  HI  RI  TI  VI  XI  lI  nI  pI  zI  |I  ~I  I  I  I  I  I  I  I  I  I  I  I  I  I  I  I  I  I  I  I  I  I  ԿԿtlth                                  h	  h	 CJ aJ  hQ= h	 CJ aJ  hs  j    hs Uh"e h"e  h"e  h"e h"e CJ aJ  h"e CJ aJ  h r  #js9  h r h r CJ  UaJ  (j    h r h r CJ  UaJ  mH nH u j    h r h r CJ  UaJ  #j8  h r h r CJ  UaJ  h r h r CJ  aJ  "~I  I  I  I              x            x                                                                                                                                                                                                     	  $If   gd"e  }  kd9  $$If   l             0 *                      
t  0                                6                            4   4 
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t  0                                6                            4   4 
l a  yt"e  I  I  I  I  I  I  I                                                                                                                                                                                                                                         gd"e      g  kd:  $$If   l F D* X                 X                 X                
t    6                                      4   4 
l a  ytQ=  $$If   a$gdQ=  6 &P 1h:pQ= / =!"#$%                                                                                                                                                                                                                                                                                                                                                                                                                                                                          Z!  D d n n   
            ((                                 B   
      
  S    A                      b    "UJE"jq       D     g n   "UJE"jqPNG

   IHDR   n   n      PLTERRRZZZccckkksss{{cBB{JJs))  9        R   kcs ! 9! Z!1 {)B) ƵcRJ{B)1 ֥9 J R ƜJ kRkZ9c9{1 ZB1{99 ƄJk)Jk ck罔k{Jք1cc ZJZ  BZ9{!Z1 s{Z{cB)ք9! {Z { ֭Ƅ{ΜJ B9)cƌsBkΥRR{Z {R  sε{Μ)BƔ{ J)sƭkcJcΜ  ֔k k{  B9 sc Jֽ { RRBssJ))RRkk  1 { k{ Rk BZ !1  !c ckkBJJsk1!199ZkR{9{kRΌRsB9Rs{Z)kB {sk1Z){!kZ)Rcc{kޥ cR Rc BޔZk!1R)Bs!9k JRZkk{!cZk!BJZ)B 1΄ 9cs1 !祥99J)    1  c       ZJR9kcB{9 RB)BRƥ{9ck 1{ !1ckc)1   1T   bKGD   cmPPJCmp0712   H s  IDAThCz|Sڴgs	@<h=)..@+9QÕuM*TWZI~Nn9U.H7;l>U":kR777{=M5=F^y^;EK(k]-By|\ :ΓL_;R	Q(XSX1]&U.{gJ$.nQ?qHU<|>r}D?+KqSl_Jኙ9lu_FusRn[)N'(÷ѽH\ C{lM ,j2m=<RrKvx'.?6~Κs.
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qި;T1O7(*Q~-5%'s"!tda%eV`nc!8?hFyۃuZL]6W"jݮJPQmWu.$cR);X;ඬ迍?,qw@IѠZ'L㷋֭^pDjnjPjA%pȭf3V&
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looaj.>`ܠ2DD>w 5u&uD~31ry@O
wBWcrM/d鄒A3ՀODLi]=SUnMW1ɞ"	0lsuCT?uτλ_,l@3HG}|ђdS~{ ԭ:lHw8\S]N؁΂ >rX-:ˈ- ~W4Xn	AJE[eRcb]O䚻ӧO1mꌩ].3Gx[-*Q/aY
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l]ߞHt@}'y Z\ﰳvEи9Ã!`#Qw<O
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 ZZKaE牤\94Y1<CcvMWW1{:;Qip,\ky*cgg6	mJN=.[&YcDDdM&D_CSRl5uF>i<9Ԟ6?wwy2Lv;rY5A\M#Z,t^&bx[|d+QST8aa֐ҸCmjDM$2"(S|67C0\Q-igd+ܽl1$r5>&ׅ+ݘn.zxZ>9:&9VB!}#Dm=FQf]dلů\!Bi=kxC ;#UY$]4I?^ޢw/U674:.F<y"[@~叝i@fj'oL7vI!9>2y<j5fswJձdȧzkL}Ն=bjA7]Jo=iơm{ec<&H\ۀOt5}	]DRȢkon6LM3ZB۠&ɪjمAD=eZHi.fHvTB,n[:z.4B2+:XiT:|5mjAY8u3Mpi8uE{ڋ~Q[i bLuZT,}Z;C}]!5E<MY/'3KW??y9_>̆&bhsGoIgR{ukt_V9^70fGV# XMv:~ZOک{a_hST",Gh$p.t~]V2	CFT^u;HU[eGڮ]rי3kx'I  $9ZԛOqI<dtο.d5=ٚoQ#--d5K~kFpM48)-n }&|~`'|n9G*jRqԙkn̶vgP4.(Qf~)8t7>mYpo;@DPc~^hҳ#)4K㣠W\y&!k$'+eT0>-kA@YJe	)T{ (=dmby]猲AuzpyvϣF[OXA&qsƬl`&a^W0;( )@'M$M*3yNY9TI\g*;_|5a,K>:!rxUSwNwSdGW`^e&Lu쪖I_]0Qצ2rCc-{Da *W*A$}폍46ufzcޡ)L{(.iL4p<d_eEyƂ	3S>A|"G7
Ad GQe/HN.W*+	z{ox9C	pz3H9S%@+gɱj1J^MB"S5)X/9xubΫ':R:B5F@&?
S1eJE`,}=p\rY[Z_ty$sI_ueeؔ<($S#b%<K'#5P,)syO|@hLYYk1nGϪTתXOшg3GKlؤǌ>hZ$`&SsXfʶM;
#rG??R_cC0ɌG*L&:(_j4ʊS2%հLii}irb>ҔڗcGM`lX=`jj,[ 1&>R<钷V* RRJ++38AWm|7_mnL-/+;3LɔM);PQ>%eʔjVV [.c.KƧzm'0**A0R5>0;T9OrIX=}cط՗#iŉd    IENDB`d $$If     !v h5 85&#v 8#v&:V l ?
t  P+l 5 85&yt* d $$If     !v h5 P+#v P+:V l 	 
t  
      P+5 +p
      yt* t   D                                                                      T e x t 1                           c $$If     !v h5 5$#v #v$:V l 
t    6  5 5$yt= t   D                                                                     T e x t 2                           c $$If     !v h5 5,"#v #v,":V l 
t    6  5 5,"yt= t   D                                                                     T e x t 3                           c $$If     !v h5 5H$#v #vH$:V l 
t    6  5 5H$yt t   D                                                                     T e x t 4                           c $$If     !v h5 5H$#v #vH$:V l 
t    6  5 5H$yt t   D                                                                     T e x t 5                           c $$If     !v h5 5H$#v #vH$:V l 
t    6  5 5H$yt t   D                                                                     T e x t 6                           c $$If     !v h5 5H$#v #vH$:V l 
t    6  5 5H$yt t   D                                                                     T e x t 7                           c $$If     !v h5 5H$#v #vH$:V l 
t    6  5 5H$yt t   D                                                               e     C h e c k 1                         c $$If     !v h5 5$#v #v$:V l 
t    6  5 5$yt t   D                                                               e     C h e c k 2                         c $$If     !v h5 5$#v #v$:V l 
t    6  5 5$yt M $$If     !v h5 +#v +:V l 
t    6  5 +yt t   D                                                                      T e x t 8                           Q $$If     !v h5 +#v +:V l &
t    6  5 +ytFx t   D                                                                     T e x t 9                           c $$If     !v h5 	5x!#v 	#vx!:V l 
t    6  5 	5x!yt v   D                                                                     T e x t 1 0                           c $$If     !v h5 58#v #v8:V l 
t    6  5 58yt>
 M $$If     !v h5 +#v +:V l 
t    6  5 +yt>
 v   D                                                                     T e x t 1 1                           Q $$If     !v h5 +#v +:V l B
t    6  5 +ytFx M $$If     !v h5 +#v +:V l 
t    6  5 +ytFx v   D                                                                     T e x t 1 2                           v   D                                                                     T e x t 1 4                           U $$If     !v h5 5#v :V l 
t    6  5 yt>
 v   D                                                                     T e x t 1 3                           v   D                                                                     T e x t 1 5                           U $$If     !v h5 5#v :V l 
t    6  5 yt>
 M $$If     !v h5 +#v +:V l 
t    6  5 +ytFx v   D                                                                     T e x t 1 6                           v   D                                                                     T e x t 1 7                           U $$If     !v h5 5#v :V l 
t    6  5 yt>
 v   D                                                                     T e x t 1 9                           v   D                                                                     T e x t 1 8                           U $$If     !v h5 5#v :V l 
t    6  5 yt>
 M $$If     !v h5 +#v +:V l 
t    6  5 +ytFx v   D                                                                     T e x t 2 0                           v   D                                                                     T e x t 2 2                           U $$If     !v h5 5#v :V l 
t    6  5 yt>
 v   D                                                                     T e x t 2 1                           v   D                                                                     T e x t 2 3                           U $$If     !v h5 5#v :V l 
t    6  5 yt>
 M $$If     !v h5 +#v +:V l 
t    6  5 +ytFx v   D                                                                     T e x t 2 4                           v   D                                                                     T e x t 2 5                           U $$If     !v h5 5#v :V l 
t    6  5 yt>
 v   D                                                                     T e x t 2 7                           v   D                                                                     T e x t 2 6                           U $$If     !v h5 5#v :V l 
t    6  5 yt>
 v   D                                                                     T e x t 2 8                           v   D                                                                     T e x t 2 9                           c $$If     !v h5 5#v :V l 
t    6  5 /      ytFx c $$If     !v h5 5#v :V l 
t    6  5 /      yt"e  $$If     !v h5 X5X5X#v X:V l 
t  0                                            65 XytQ=                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                R  @ R    '    N o r m a l      ) B*CJ OJ QJ _HaJ mH	ph    sH	tH	                   D A  D          D e f a u l t   P a r a g r a p h   F o n t     R i@ R          T a b l e   N o r m a l      4 
l 4   a      ( k  (           N o   L i s t          4 @  4   Q=    H e a d e r      !   4  @ 4   Q=    F o o t e r      !   j @ j   Q=   
 T a b l e   G r i d   7 :V 0                                   H @ "H   s    B a l l o o n   T e x t      CJ OJ QJ ^J aJ         n          )   =   [   \   A  B  C  Q  g  h  i                                    *  +  ,  ;        |  }  ~            ;  O  P  Q          \  ]  q  r  s  	  	  	  	  	  
  F
  G
  H
  I
  g
  
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                                                                      !   "   #   $   %   &   '   (   )   *   +   ,   -   .   /   0   1   2   3   4   5   6   7   9   :   ;   <   =   >   ?   @   A   B   C   D   E   F   G   H   I   J   K   L   M   N   O   P   Q   R   S   T   U   W   X   Y   Z   [   \   ]   ^   _   `   a   b   c   d   e   f   g   h   j   k   l   m   n   o   p   r   s   t   u   v   w   x   {   R o o t   E n t r y                                                 	           F             h2}          D a t a                                                         
                                     8   @;      1 T a b l e                                                                                                V   %      W o r d D o c u m e n t                                                                                        8n       S u m m a r y I n f o r m a t i o n                           (                                     i           D o c u m e n t S u m m a r y I n f o r m a t i o n           8                                        q           C o m p O b j                                                                                           q                                                                                                                               
  	           F   Microsoft Office Word Document 
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