Child Care Power Of Attorney Form - Hamilton County Juvenile Court (Page 4 of 10) in pdf

Child Care Power Of Attorney Form - Hamilton County Juvenile Court Page 4

If there is a court order naming me the residential parent and legal custodian of the child who is the subject of

this power of attorney and I am the sole parent signing this document, I hereby certify that one of the following

is the case:

(1) I have made reasonable efforts to locate and provide notice of the creation of this power of attorney to the

other parent and have been unable to locate that parent;

(2) The other parent is prohibited from receiving a notice of relocation; or

(3) The parental rights of the other parent have been terminated by order of a juvenile court.

This POWER OF ATTORNEY is valid until the occurrence of whichever of the following events occurs first:

(1) I revoke this POWER OF ATTORNEY in writing; (2) the child ceases to reside with the grandparent

designated as attorney in fact; (3) this POWER OF ATTORNEY is terminated by court order; (4) the death of

the child who is the subject of the power of attorney; or (5) the death of the grandparent designated as the

attorney in fact.

WARNING: DO NOT EXECUTE THIS POWER OF ATTORNEY IF ANY STATEMENT MADE IN

THIS INSTRUMENT IS UNTRUE. FALSIFICATION IS A CRIME UNDER SECTION 2921.13 OF

THE REVISED CODE, PUNISHABLE BY THE SANCTIONS UNDER CHAPTER 2929. OF THE

REVISED CODE, INCLUDING A TERM OF IMPRISONMENT OF UP TO 6 MONTHS, A FINE OF

UP TO $1,000, OR BOTH.

Witness my hand this

day of

Parent/Custodian/Guardian's signature

Parent's signature

Grandparent designated as attorney in fact (signature)

State of Ohio

)

) ss:

County of

)

Subscribed, sworn to, and acknowledged before me this

day of

, Notary Public

Notices:

1. A power of attorney may be executed only if one of the following circumstances exists: (1) The parent,

guardian, or custodian of the child is: (a) Seriously ill, incarcerated or about to be incarcerated; (b) Temporarily

unable to provide financial support or parental guidance to the child; (c) Temporarily unable to provide

Page 2 of 5

Form 1349

Child Care Power Of Attorney Form - Hamilton County Juvenile Court Page 4