Authorization Form For Temporary Guardianship Of Minor - Northern Virginia (Page 3 of 3) in pdf

Authorization Form For Temporary Guardianship Of Minor - Northern Virginia Page 3

The following is to be completed by the Temporary Guardian while in the presence of a Notary

Public. Do not sign this document until identification is presented to the Notary Public and you

are instructed to do so.

CONSENT OF TEMPORARY GUARDIAN

I hereby acknowledge the terms set forth above and agree to assume responsibility in accordance with

those terms. Under penalty of perjury under the laws of the state of ______________________, I attest to

the truthfulness, accuracy, and validity of the forgoing statement.

Temporary Guardian 1’s Signature: ________________________________ Date: __________________

Print Name: _________________________________

Temporary Guardian 2’s Signature: ________________________________ Date: __________________

Print Name: _________________________________

CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC

STATE OF __________________________

COUNTY OF ________________________

This document was acknowledged before me on ______________________ [date] by

________________________________________________ [name of principal].

[Notary Seal, if any]:

__________________________________________

(Signature of Notarial Officer)

Notary Public for the State of __________________

My Commission Expires: _____________________

Authorization Form For Temporary Guardianship Of Minor - Northern Virginia Page 3