IDesILaytags 12141610831 p4j {_Hb:VD|a{ &,28>DJPV\bhntz6ZSubmit 6 |T6^6$64*50469041744506000jB"X  " @@@@@@ @@@@@|Zg ZSS S"|0/4S0"/|5 dgSZ S/x   0/*0/**?>D0/hID?>TXPiID\IRxIiIZxIwIF{IDdDɫD֫D( #bDDz,ORDS@@@  @@X  D,z @@@  @@X  D,z @@@   @@X  D,z @@RbD8z,OR@@ H"rz   "  ߰N߰N߰N߰N߰O߰O?b߰N porpsilaT porpsilaZ<E porpsilaf porpsilalArialTimes New Romanii\;y4f(\+NT3Submit H` 1214161083 SS" 1S"|Z/$SZ ) S/hf````d'@L! $ od6bl6xthis: SignatureVersion  Data Vers $ Blue Keys*Graphics $ 0Header$  6 FieldList$ < Form Info` LayoutProps" r DesPathInfo" x(&p~%pP 1.3 The child:   > p @  v Is a member of the  *Q  PH 0  wTitle  @"0 Tribe. The Tribe's address:   u P!H 0  xTitle  p @  y  !Is eligible for membership in the  * @ !H 0  zTitle    P The Tribe's address is:   b  @!H 0  {Title  pp!@  |p! Is of Indian ancestry and may be a member of or eligible for membership in a federally recognized Indian Tribe. Further efforts will be made by the petitioner to ascertain whether the child is an Indian child as defined by the Indian Child Welfare Act. The following efforts have been made to verify whether the child is Indian and to identify the tribal affiliation of the child and the parents/Indian custodian:  zzo1& zo&1  o1&,Arial (zWIs of Indian ancestry and may be a member of or eligible for membership in a federally (zbrecognized Indian Tribe. Further efforts will be made by the petitioner to ascertain whether the ( zachild is an Indian child as defined by the Indian Child Welfare Act. The following efforts have (zhbeen made to verify whether the child is Indian and to identify the tribal affiliation of the child and ($zthe parents/Indian custodian:p!H 0  }Title  Pp *1.4 Tribal affiliation of child's mother:    P %Tribal affiliation of child's father:    00!H 0  Title   /Tribal affiliation of child's Indian custodian:    `0!H 0  Title  pp 1.5    p@  p R>The child's residence/domicile is located within the reservation boundaries of the    !  @ 0H 0  Title   @"0 Tribe.    "@  " ]>The child's residence/domicile is not located within the boundaries of an Indian reservation.    %   !!@   !! There is not enough information available at this time to determine whether the child's residence/domicile is within an Indian reservation.  ,,r## ,r##  r##,Arial ( }XThere is not enough information available at this time to determine whether the child's (}3residence/domicile is within an Indian reservation."$!H 0  Title  , - !  Page 2 of 4 )  ` 0Tribe and is the birth child of a tribal member.    " p" [1.6 The position of the child's Tribe regarding the child's residence/domicile (if known):   v  P!H1 0  Title  @!H2 0  Title  ,`-  PADDENDUM TO PETITION FOR AN INDIAN CHILD DSHS 09-771 (REV. 08/1991) (AC 10/2002)? ?  ?,Arial (I)ADDENDUM TO PETITION FOR AN INDIAN CHILD (I'DSHS 09-771 (REV. 08/1991) (AC 10/2002)$`%` 1.7    $% @3  $%  The child  *' $ % `@4   $ % P is  * $ @%!@5 P  $ `%! Kis not the subject of any Tribal Court custody order. A copy of each such  *@ &P'@ @6  &`'@  The child  *' &P '@ p@7   &` '@ ` is  * &P '@!p@8   &` '@!` is not a ward of Tribal Court.  *z ')!@9  ')! iThere is not enough information available at this time to determine if the child is a Tribal Court ward.    pp"  pp" ? pp",Arial ({dThere is not enough information available at this time to determine if the child is a Tribal Court ({ward.%&P order is attached.   L *p+ dDISTRIBUTION: Attach to the petition; Service file; Indian Child's parents; Indian Child's Tribe    ,Arial (_DISTRIBUTION: Attach to the petition; Service file; Indian Child's parents; Indian Child's (Tribe$+29@GhNU\cjqxij$k*l0Cell1Cell2Cell3Cell4Cell5Cell6Cell7Cell8Cell9Cell10Cell11Cell12Cell13Cell14Cell15Cell16Cell17Cell18Cell19Cell20Cell21Cell22Cell23Cell24Cell25Cell26Cell27Cell28Cell29Cell30Cell31Cell32Cell33Cell34Cell35Cell36Cell37Cell38Cell39Cell40Cell41Cell42Cell43Cell44Cell45Cell46Cell47Cell48Cell49Cell50Cell51Cell52Cell53Cell54Cell55Cell56Cell57Cell58Cell59Cell61Cell62Cell63V@ !H 0  Title  pP0 Z1.8 A specific and detailed account of the circumstances that led to filing the petition:   t   ! 1.9 A statement of specific active efforts made to provide remedial and rehabilitative services designed to prevent the break-up of the Indian family (attach documentation of services provided):  N# N#  N#,Arial (Xa1.9 A statement of specific active efforts made to provide remedial and rehabilitative services (X_ designed to prevent the break-up of the Indian family (attach documentation of services (X provided): !H 0  Title  ! `A statement as to whether those efforts proved unsuccessful and the reasons for lack of success:    !H 0  Title   2. The child   > ` @@  p    0 is   *  @!@! P   `! Iis not in shelter care placement (provide the information requested below   *^  3 only if the child has been placed in shelter care.    `! |2.1 A specific and detailed account of the circumstances that led the service worker to seek shelter care placement:  L# L# N# L#,Arial (Vf2.1 A specific and detailed account of the circumstances that led the service worker to seek shelter (V care placement:P 0!H" 0  Title  ,0- !  Page 3 of 4 ) `!` Y2.2 Reasons why the child has not been transferred to the jurisdiction of his/her Tribe:   u !`&@!H# 0  Title  &P' 2.3 The child's Tribe    \ & 0' @: @  & P' p has  * & '$ @;  &'$ Fhas not concurred in the dependency petition. The believed basis for   *, '(P ,the Tribe's concurrence/lack of concurrence:    (0+`"H< 0  Title  ,P- PADDENDUM TO PETITION FOR AN INDIAN CHILD DSHS 09-771 (REV. 08/1991) (AC 10/2002)> >  >,Arial (H)ADDENDUM TO PETITION FOR AN INDIAN CHILD (H'DSHS 09-771 (REV. 08/1991) (AC 10/2002)+p, dDISTRIBUTION: Attach to the petition; Service file; Indian Child's parents; Indian Child's Tribe   > ,Arial (_DISTRIBUTION: Attach to the petition; Service file; Indian Child's parents; Indian Child's (Tribele, Indian child's parents, Indian child's Tribe ADDENDUM TO PETITION FOR AN INDIAN CHILD (I_DSHS 09-771 (REV. 00/0000) PROPOSED REVISION - DO NOT PRINT - TONI BENHAM - 664-6047 - ms 45805,0- !  Page 3 of 4 q)& & Y2.2 Reasons why the child has not been transferred to the jurisdiction of his/her Tribe:  q  &+!H0 0  Title  p0 ( copy of each such order(s) is attached.  q    Title  p0 ( copy of each such order(s) is attached.   Title  p0 ( copy of each such order(s) is attached.   is/her Tribe:&+!H1 0  Title  ial and rehabilitative services designed to prevent the break-up of the Indian family (attach documentation of services provided):  hh>(& h>&( = >(&,Arial (Hm1.9 A statement of specific active efforts made to provide remedial and rehabilitative services designed to (D|`Pp G2.4 A statement of the "reasonable efforts" made to prevent placement:   6  ` " 2.5 A statement of the specific actions that have been taken or will be taken to assist the parents or Indian custodian to obtain the return of the child to their custody:  LLL5 LL5  L5,Arial (Vo2.5 A statement of the specific actions that have been taken or will be taken to assist the parents or Indian (V=custodian to obtain the return of the child to their custody:0 !H$ 0  Title  0! tI declare under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct.  ?% ?% L5 ?%,Arial (IcI declare under penalty of perjury under the laws of the State of Washington that the foregoing is (Itrue and correct.#p#  DECLARANT*% % ADDRESS $&'@ CITY    DAY 0 ` MONTH @  YEAR 0  CITY` `H%` Title  p @  Dated this   ,  @ day of     @ H&` Title  p 0 ,      H'` Title  @ @ at     H(` Title   @"  , Washington.   = "P#p!H)` Title  $% !H*` Title  %&H+` Title  %&@H,` Title  %&!H-` Title  &'@  STATE&`'0   ZIP CODE$,0- !  Page 4 of 4 ) !H. 0  Title    Signed at   ) 0@H=` Title  P , Washington,    @ ,`-  PADDENDUM TO PETITION FOR AN INDIAN CHILD DSHS 09-771 (REV. 08/1991) (AC 10/2002)? ?  ?,Arial (I)ADDENDUM TO PETITION FOR AN INDIAN CHILD (I'DSHS 09-771 (REV. 08/1991) (AC 10/2002)*, dDISTRIBUTION: Attach to the petition; Service file; Indian Child's parents; Indian Child's Tribe   ? ,Arial (_DISTRIBUTION: Attach to the petition; Service file; Indian Child's parents; Indian Child's (TribeD (I_DSHS 09-771 (REV. 00/0000) PROPOSED REVISION - DO NOT PRINT - TONI BENHAM - 664-6047 - ms 45805,0- !  Page 4 of 4 u)!H? 0  Title  e   fa{N` IN THE MATTER OF:   \ `"`  Xh!``!` P CHILD'S FULL NAMEEP  BIRTHDATE'` TRIBE(S)/BAND(S)< p    &SUPERIOR COURT OF WASHINGTON COUNTY OF  @  @   @ ,Arial (JSUPERIOR COURT OF WASHINGTON (J COUNTY OF0`! (ADDENDUM TO PETITION FOR AN INDIAN CHILD  ,C ,C @  ,C,Arial (+6#ADDENDUM TO PETITION FOR AN INDIAN (66CHILDpp LEGAL NO:   4  0H 0 dTitle  P`H 0 eTitle  H 0 fTitle  P`H 0 gTitle  `p!@ 0 hTitle  ! @The following information is to be filed with the Superior Court with a dependency, guardianship, or termination petition pursuant to an agreement for the delivery of Indian child welfare services between the federally recognized Indian Tribes of the State of Washington and the Department of Social and Health Services.  e>% >e%  e>%,Arial (wHeThe following information is to be filed with the Superior Court with a dependency, guardianship, or (Hltermination petition pursuant to an agreement for the delivery of Indian child welfare services between the (Hffederally recognized Indian Tribes of the State of Washington and the Department of Social and Health (H Services.p 1. I,     @H 0  iTitle  0p" , hereby declare:   I ,`-  PADDENDUM TO PETITION FOR AN INDIAN CHILD DSHS 09-771 (REV. 08/1991) (AC 10/2002)> > e>% >,Arial (H)ADDENDUM TO PETITION FOR AN INDIAN CHILD (H'DSHS 09-771 (REV. 08/1991) (AC 10/2002),0-!  Page 1 of 4 ) !H 0  jTitle  P!H 0  kTitle  0 0 P!H  0  lTitle   ` !!H  0  mTitle  ! "!H  0  nTitle  " p#!H  0  oTitle  # &@!H  0  pTitle  ` 1.1 Name of the Indian child:    @ Date of birth:   8  0H/ 0  Title  @ 0 Last known address:   Z ` ` 1.2 Name of child's mother:   z  !0  Address of child's mother:   t !" Name of child's father:   ` ## Address of child's father:   k $0$@ Name of Indian custodian:   q &`'! jEfforts made to locate parents/Indian custodian if the identity or whereabouts of such person are unknown:    \`$  `\$  \`$,Arial (njbEfforts made to locate parents/Indian custodian if the identity or whereabouts of such person are (zjunknown:'+!H0 0  uTitle  +, dDISTRIBUTION: Attach to the petition; Service file; Indian Child's parents; Indian Child's Tribe    ,Arial (_DISTRIBUTION: Attach to the petition; Service file; Indian Child's parents; Indian Child's (TribetTitle  Title  {_<=dm6n=oDpKu@vRewYx`ygzn{u||}f U\cgjqxhi$+29GNj$k*l0Cell1Cell2Cell3Cell4Cell5Cell6Cell7Cell8Cell9Cell10Cell11Cell12Cell13Cell19Cell20Cell21Cell22Cell23Cell24Cell25Cell26Cell29Cell30Cell31Cell32Cell33Cell34Cell35Cell37Cell44Cell45Cell46Cell47Cell48Cell49Cell53Cell54Cell55Cell56Cell57Cell58Cell59Cell61Cell62Cell63Cell64Cell65Cell18Cell66Cell67Cell36Cell38Cell39Cell40Cell41Cell42Cell43Cell50Cell51Cell52Cell6861Cell62Cell63Cell17Cell64day of   p @0Wv@@X   @@@@@@ @@@@@*> 0/*0/**?>D0/hID?>TXPiID\IRxIiIZxIwIF{IDdDɫD֫D( #bDDz,ORDS@@@  @@X  D,z @@@  @@X  D,z @@@   @@X  D,z @@RbD8z,OR@@X D,z LBHN~