Fillable Caretaker Authorization Affidavit (Page 2 of 4) in pdf

Caretaker Authorization Affidavit Page 2

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I declare that the foregoing is true and correct:

Signed: _________________________________________ Date: ______________________________

Grandparent

State of Ohio)

SS:

County of ____________________)

Subscribed, sworn to, and acknowledged before me this _____________ day of _________.

20_____.

__________________________________________________

Notary Public

Notices:

1. The grandparent’s signature must be notarized by an Ohio notary public.

2. The grandparent who executed this affidavit must file it with the juvenile court of the county in

which the grandparent resides or any other court that has jurisdiction over the child under a

previously filed motion or proceeding not later than five days after the date it is executed.

3. This affidavit does not affect the rights of the child’s parents, guardian, or custodian regarding the

care, physical custody, and control of the child, and does not give the grandparent legal custody

of the child.

4. A person or entity that relies on this affidavit, in good faith, has no obligation to make any further

inquiry or investigation.

5. This affidavit terminates on the occurrence of whichever of the following occurs first: (1) the

child ceases to live with the grandparent who signs this form; (2) the parent, guardian, or

custodian of the child acts to negate, reverse, or otherwise disapprove an action or decision of the

grandparent who signed this affidavit, and the grandparent either voluntarily returns the child to

the physical custody of the parent, guardian, or custodian or fails to file a complaint to seek

custody within fourteen days; (3) the affidavit is terminated by court order; (4) the death of the

child who is the subject of the affidavit; or (5) the death of the grandparent who executed the

affidavit.

6. The decision of a grandparent to consent to or to refuse medical treatment or school enrollment

for a child is superseded by a contrary decision of a parent, custodian, or guardian of the child,

unless the decision of the parent, guardian, or custodian would jeopardize the life, health, or

safety of the child.

Additional information:

To caretakers:

1. If the child stops living with you, you are required to notify, in writing, any school, health care

provider, or health care insurance provider to which you have given this affidavit. You are also

required to notify, in writing, any other person or entity that has an ongoing relationship with you

Caretaker Authorization Affidavit Page 2

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