Use of this affidavit is authorized by O.C.G.A. Section 20-1-16.
INSTRUCTIONS: Please print clearly.
I hereby certify that the child named below lives in my home and I am 18 years of age or older.
[ ] A parent being unable to provide care due to the death of the other parent;
[ ] A serious illness or terminal illness of a parent;
[ ] The physical or mental condition of the parent or the child such that proper care and supervision of the child cannot be provided by the parent;
[ ] The incarceration of a parent;
[ ] The loss or uninhabitability of the child’s home as the result of a natural disaster;
[ ] A period of active military duty of a parent exceeding 24 months; or
[ ] I am unable to locate a parent or parents at this time to notify them of my intended authorization because (list reasons):
_________ .
WARNING: DO NOT SIGN THIS FORM IF ANY OF THE STATEMENTS ABOVE ARE INCORRECT OR YOU WILL BE COMMITTING A CRIME PUNISHABLE BY A FINE, IMPRISONMENT, OR BOTH.
I recognize that if I knowingly and willfully make a false statement in this affidavit, I will be guilty of the crime of false swearing.
_______________
(Kinship caregiver’s signature)
_______________
(Kinship caregiver’s printed name)
Sworn to and subscribed
before me this _______________
day of _______________ , _______________ .
Notary public (SEAL)
My commission expires: _______________ .
“KINSHIP CAREGIVER’S AFFIDAVIT
NOTICES:
ADDITIONAL INFORMATION:
TO KINSHIP CAREGIVERS:
TO SCHOOL OFFICIALS:
The school system may require additional reasonable evidence that the kinship caregiver resides at the address provided in item 4 of the affidavit.
TO HEALTH CARE PROVIDERS AND HEALTH CARE SERVICE PLANS:
History. Code 1981, § 20-1-18 , enacted by Ga. L. 2017, p. 113, § 2/SB 186; Ga. L. 2019, p. 1056, § 20/SB 52.
The 2019 amendment, effective May 12, 2019, part of an Act to revise, modernize, and correct the Code, at the end of the kinship caregiver’s affidavit in subsection (b), under notices and additional information, substituted “person who” for “person that” in two places, and revised punctuation in paragraph (2) under “TO KINSHIP CAREGIVERS:”.
Structure Georgia Code