MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S 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 the child’s other parent are entitled to membership in a tribe.
Your name:
2. Relationship to Child:
3. Name of child:	1.
2.
3.
4.
5.
4. Check one:	I have no information regarding any Indian ancestry of the child/children listed on this form. (If you have no such information, you may skip questions 5 – 9. Please sign and date at bottom of form).
Yes, I have information or belief that the child/children has Indian Ancestry.
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 pages.
Name of tribe or tribes:
Many tribes use both traditional and official names. If you know any additional names that the child/children’s tribe(s) may be known by, please provide this information:
If different from name of tribe, please list name of reservation, Rancheria, pueblo, or Alaskan Native village, if known (if more than one, please list all). If this information does not apply to all children listed, please state as to which child it applies. Please feel free to attach additional pages if necessary.
If you have information that the child/children, either parent or any grandparent is an enrolled member of any tribe, please state who is enrolled; their relationship to the child/children; which tribe; and provide enrollment number if you know it. If you need more space, please attach additional pages.
(A) Name:	Relationship to child/children:
Tribe:	Enrollment Number:
(B) Name:	Relationship to child/children:
Tribe:	Enrollment Number:
(C) Name:	Relationship to child/children:
Tribe:	Enrollment Number:
(D) Name:	Relationship to child/children:
Tribe:	Enrollment Number:

CERTIFICATION

I have answered this questionnaire to the best of my knowledge and believe the answers are true.

Signature	Date