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Statutory Form for Power of Attorney to Delegate Parental or Legal Custodian Powers 1. "I certify that I am the parent or legal custodian of: (Full name of minor child) (Date of birth) (Full name of minor child) (Date of birth) (Full name of minor child) (Date of birth) who is/are minor children. 2. I designate as the attorney-in-fact for each minor child named above: as the attorney-in-fact of each minor child named above. (Full name of attorney-in-fact) (Street address, city, state and zip code of attorney-in-fact) (Home phone, work phone and cell phone of attorney-in-fact) 3. [Complete either Section 3(a) or 3(b)]. (a) I delegate to the attorney-in-fact all of my power and authority regarding the care, custody and property of each minor child named above, including, but not limited to, the right to enroll the child in school, inspect and obtain copies of education records and other records concerning the child, the right to attend school activities and other functions concerning the child, and the right to give or withhold any consent or waiver with respect to school activities, medical and dental treatment, and any other activity, function or treatment that may concern the child. This delegation shall not include the power or authority to consent to marriage or adoption of the child, the performance or inducement of an abortion on or for the child, or the termination of parental rights to the child. OR (b) I delegate to the attorney-in-fact the following specific powers and responsibilities (write in): [If Section 3(b) is completed, Section 3(a) does not apply.] This delegation shall not include the power or authority to consent to: marriage or adoption of the child, performing or inducing an abortion on or for the child, or the termination of parental rights to the child. (c) The reason or reasons for this transfer of custody is as follows: [Complete either 4(a) or 4(b)] 4. (a) This power of attorney is effective for a period not to exceed one (1) year, beginning , 20, and ending, 20 I reserve the right to revoke this authority at any time. OR [Complete either 4(a) or 4(b)] (b) I am a serving parent as defined in Section 93-31-3, Mississippi Code of 1972. My active-duty service is scheduled to begin on , 20, and is estimated to end on , 20. I reserve the right to revoke this authority at any time. I acknowledge that in no event may this delegation of power last more than one (1) year or the term of my active duty plus thirty (30) days, whichever is longer. By: (Parent/Legal Custodian signature) 5. I hereby accept my designation as attorney-in-fact for the minor child/children specified in this power of attorney. (Attorney-in-fact signature) 6. AFFIDAVIT OF FACILITATING AGENCY UNDER SECTION 93-31-3(1)(d), Mississippi Code of 1972 I, of (Agency), do hereby certify that I have properly vetted the proposed designated attorney-in-fact as required under and find no criminal or child abuse or neglect history. Section 93-31-3(1)(d), Mississippi Code of 1972, (Agency representative signature) Name of facilitating agency State of County of ACKNOWLEDGEMENT Before me, the undersigned, a Notary Public, in and for said county and state on this day of , 20, personally appeared and , known to me to be the persons who executed this instrument and who acknowledged to me that each executed the same as his or her free and voluntary act and deed for the uses and purposes set forth in the instrument. (Name of facilitating agency and person signing as facilitator), (Name of Parent/Legal Custodian) (Name of Attorney-in-fact) Witness my hand and official seal the day and year above written. (Signature of notarial officer) (Seal, if any) (Title and Rank) My commission expires:" 7. If the custodial parent alleges that the noncustodial parent is absent, unknown, or that the location of the noncustodial parent is unknown, an affidavit must be completed and attached to the power of attorney. The following statutory form is sufficient: Affidavit of Custodial Parent STATE OF COUNTY OF I hereby certify that I am the custodial parent of the child(ren)_who are the subject of the power of attorney to which this affidavit is attached. I further certify that the location of the noncustodial parent, is unknown to me or that the identity of the father is unknown to me (insert here if the father is unknown) or that the noncustodial parent is unavailable (state here the reason unavailable): . SO SWORN, this the day of , 20 Custodial Parent SWORN TO AND SUBSCRIBED BEFORE ME, the undersigned authority in and for the aforementioned jurisdiction, the within named person who first presented proof of identity. THIS, the day of , 20.. NOTARY PUBLIC My commission expires:
Statutory Form for Revocation of Power of Attorney to Delegate Parental or Legal Custodial Powers 1. "I certify that I am the parent or legal custodian of: (Full name of minor child) (Date of birth) (Full name of minor child) (Date of birth) (Full name of minor child) (Date of birth) who is/are minor children. 2. On the day of , 20, I designated as the attorney-in-fact of each minor child named above: (Full name of attorney-in-fact and DOB) (Street address, city, state and zip code of attorney-in-fact) 3. I hereby certify that I am revoking said Power of Attorney to Delegate Parental or Legal Custodial Powers and am requesting that my child or children named above be immediately returned to my legal and physical care, custody and control and that I resume all legal rights and responsibilities associated with my child or children. ACKNOWLEDGEMENT Before me, the undersigned, a Notary Public, in and for said county and state on this day of , 20, personally appeared , known to me to be the person who executed this instrument and who acknowledged to me that he or she executed this instrument as his or her free and voluntary act and deed for the uses and purposes set forth in the instrument. (Name of Parent/Legal Custodian) Witness my hand and official seal the day and year above written. (Signature of notarial officer) (Signature of notarial officer) (Seal, if any) (Title and Rank) My commission expires:"