Power Of Attorney Form (Page 2 of 8) in pdf

Power Of Attorney Form Page 2

I hereby certify that I am transferring the rights and responsibilities designated in this

power of attorney because one of the following circumstances exists:

(1) I am:

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 adequate care and supervision of the

child because of my physical or mental condition,

d. Homeless or without a residence because the current residence is

destroyed or otherwise uninhabitable, or

e. In or about to enter a residential treatment program for substance

abuse;

(2) I am a parent of the child, the child's other parent is deceased, and I have

authority to execute the power of attorney; or

(3) I have a well-founded belief that the power of attorney is in the child's best

interest.

I hereby certify that I am not transferring my rights and responsibilities regarding the

child for the purpose of enrolling the child in a school or school district so that the

child may participate in the academic or interscholastic athletic programs provided

by that school or district.

I understand that this document does not authorize a child support enforcement

agency to redirect child support payments to the grandparent designated as attorney

in fact. I further understand that to have an existing child support order modified or a

new child support order issued, administrative or judicial proceedings must be

initiated.

______________________________________________________________________________________

Power of Attorney Form

Authorized by Section 3109.52 of the Ohio Revised Code

Page 2 of 8

Power Of Attorney Form Page 2