Caretaker Authorization Affidavit

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CARETAKER AUTHORIZATION AFFIDAVIT
Use of this affidavit is authorized by sections
3109.65
to
3109.73
of the Ohio Revised Code.
Completion of items 1-7 and the signing and notarization of this affidavit is sufficient to authorize the
grandparent signing to exercise care, physical custody, and control of the child who is its subject,
including authority to enroll the child in school, to discuss with the school district the child’s educational
progress, to consent to all school-related matters regarding the child, and to consent to medical,
psychological, or dental treatment for the child.
The child named below lives in my home, I am 18 years of age or older, and I am the child’s grandparent.
1. Name of Child: ________________________________________________________________
2. Child’s date and year of birth: ____________________________________________________
3. Child’s social security number (optional): ____________________________________________
4. My name: _____________________________________________________________________
5. My home address: ______________________________________________________________
6. My date and year of birth: ________________________________________________________
7. My Ohio driver’s license number or identification card number: __________________________
8. Despite having made reasonable attempts, I am either:
(a) Unable to locate or contact the child’s parents, or the child’s guardian or custodian; or
(b) I am unable to locate or contact one of the child’s parents and I am not required to contact
the other parent because paternity has not been established; or
(c) I am unable to locate or contact one of the child’s parent and I am not required to contact
the other parent because there is a custody order regarding the child and one of the
following is the case:
(i) The parent has been prohibited from receiving notice of a relocation; or
(ii) The parental rights of the parent have been terminated.
9. I hereby certify that this affidavit is not being executed 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. 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.
WARNING: DO NOT SIGN THIS FORM IF ANY OF THE ABOVE STATEMENTS ARE
INCORRECT. 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.

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