Laws
Sample
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COUNTY OF [COUNTY NAME]
1. My name is [PARENT / GUARDIAN NAME]. I am the parent of [MINOR CHILD NAME]. My child’s birthdate is [MM/DD/YYYY]
2. I appoint [ATTORNEY-IN-FACT NAME], to be my legal Attorney-in-Fact to have parental authority over my child, [MINOR CHILD NAME].
Note: Attorney-in-Fact is what the person you name to care for your child is called. That person does not have to be an attorney.
This DOPA lasts: (check one)
☐ For one year from the date of my signature
OR
☐ until [MM/DD/YYYY], which is less than one year following the date of my signature.
3. This DOPA gives my Attorney-in-Fact permission to care for and make decisions about my child named above. These decisions include, but are not limited to:
a. Getting medical treatment for my child
b. Enrolling my child in school
c. Providing a home, care, and supervision of my child
4. This DOPA does not give my Attorney-in-Fact permission to consent to the marriage or adoption of my child.
5. I understand that by law I have to give or mail a copy of this document to any other parent within 30 days of signing it unless:
a. The other parent does not have parenting time rights or has supervised parenting time rights
OR
b. There is an existing Order for Protection in effect against the other parent to protect me or my child.
SIGNATURES
I swear that everything I have stated in this document is true and correct.
Parent/Guardian Signature: _______________________ Date: ______________
Print Name: _______________________
Subscribed and sworn before me this ____ day of _____, 20___.
Notary Public Signature: _______________________
Attorney-in-Fact: (the Attorney-in-Fact does not have to sign in front of a notary)
I accept the responsibilities of Attorney-in-Fact for [MINOR CHILD NAME].
Attorney-in-Fact Signature: _______________________ Date: ________________
Pring Name: _______________________