Form Jdf 559 - Affidavit And Advisement Concerning The Child'S Potential Placement (Page 3 of 3) in pdf

Mailing Address: ____________________________________________________________________________

Home Telephone Number: ___________________________ Cell Number: ______________________________

Comments regarding the appropriateness of the child’s potential placement with this relative:

__________________________________________________________________________________________

Family Member

Full Name: _____________________________________________ Relationship: ________________________

Home Address: _____________________________________________________________________________

Mailing Address: ____________________________________________________________________________

Home Telephone Number: ___________________________ Cell Number: ______________________________

Comments regarding the appropriateness of the child’s potential placement with this relative:

__________________________________________________________________________________________

Family Member

Full Name: _____________________________________________ Relationship: ________________________

Home Address: _____________________________________________________________________________

Mailing Address: ____________________________________________________________________________

Home Telephone Number: ___________________________ Cell Number: ______________________________

Comments regarding the appropriateness of the child’s potential placement with this relative:

__________________________________________________________________________________________

(Attach more sheets if necessary.)

I/We swear under penalty of perjury that the above information is true and correct to the best of my knowledge

and is a full and true disclosure of all information that is requested.

_____________________________________

______________________________________

Parent Signature

Date

Parent Signature

Date

Subscribed and affirmed, or sworn to before me

in the County of ________________________,

in the County of _________________________,

State of ____________________, this _______

State of ___________________, this ________

day of ________________, 20 ____.

My Commission Expires:

Notary Public/Clerk

The County Department of Social Services, each parent, the Guardian Ad Litem, and Counsel for each parent shall receive a copy of

this form.

JDF 559 7/05 AFFIDAVIT AND ADVISEMENT CONCERNING THE CHILD’S POTENTIAL PLACEMENT

Page 3 of 3

Form Jdf 559 - Affidavit And Advisement Concerning The Child'S Potential Placement Page 3