JFS 01646 - Indian Child Placement Report

Tribal Membership

Enter the name of the tribe in which the child is a member.

Date Verified

Enter the date on which the child's membership was confirmed.

Name of Indian Organization

Enter the name of the Indian organization.

Address of Indian Organization

Enter the mailing address of the organization.

Court of Jurisdiction

Enter the name of the court jurisdiction.

Complete by

Select the name of the worker who is completing this report.

Title

Enter the title of the worker completing this report.

Date Completed

Enter the date this report was completed.