Affidavit Of Natural Tutorship Of Disabled Child Form Msd62 - Lasers
Download a blank fillable Affidavit Of Natural Tutorship Of Disabled Child Form Msd62 - Lasers in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Affidavit Of Natural Tutorship Of Disabled Child Form Msd62 - Lasers with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1Form MSD62
R112011
AFFIDAVI
DO NOT FAX FORM
PRINT ALL INFORMATION
P.O. Box 44213, Baton Rouge, LA 70804-4213
225.922.0600 · Toll-Free 1.800.256.3000
225.922.0612 (hearing impaired)
Affidavit of Natural Tutorship of Disabled Child
Deceased Member's First Name
Middle Name
Last Name
Deceased Member's SSN
SECTION 1: DISABLED CHILD'S INFORMATION
Last Name
Disabled Child's First Name
Middle Name
Disabled Child's Social Security Number
Birth Date
Male
Female
SECTION 2: NATURAL TUTOR'S INFORMATION
Natural Tutor's First Name
Middle Name
Last Name
Natural Tutor's Social Security Number
Mailing Address
City
State
Zip Code
Daytime Area Code/Phone Number
Evening Area Code/Phone Number
E-mail Address
SECTION 3: NATURAL TUTOR'S CERTIFICATION AND AUTHORIZATION
I attest that I am the natural tutor and have custody of the above named fully disabled, and/or fully dependent child who is a surviving
beneficiary of the above named deceased member. I certify that I will be a prudent administrator of any funds issued for the benefit of the
said fully disabled, and/or fully dependent child.
Date
Natural Tutor's Signature
SECTION 4: NOTARIZATION
SWORN TO AND SUBSCRIBED BEFORE ME, Notary Public, in and for the state of _____________________, parish/county of_______________,
this _______ day of ________, 20____.
____________________________________
_______________________________________
Notary Public (Signature)
Notary ID # or Bar Roll #
____________________________________
_______________________________________
Notary Public Name
Commission Expires
(affix seal here)
Reset Form
MSD62 R
RETAIN A COPY FOR YOUR RECORDS
AFFIDAVI Page 1 of 1
112011
ADVERTISEMENT
0 votes
Related Articles
Related forms
Affidavit Of Parental Consent Form - For Travel Outside The United States Of A Minor Child - Without Both Birth Parents Traveling
Legal
Form C-10a - Affidavit Of Substantial Hardship Form - State Of Alabama Unified Judicial System
Legal
Related Categories
Parent category: Legal