Fillable Caretaker Authorization Affidavit (Page 3 of 4) in pdf

or the child such that the person or entity would reasonably rely on the affidavit unless notified.

The notifications must be made not later than one week after the child stops living with you.

2. If you do not have the information requested in item 7 (Ohio driver's license or identification

card), provide another form of identification such as your social security number or medicaid

number.

3. You must include with the caretaker authorization affidavit the following information:

(a) The child's present address, the addresses of the places where the child has lived within

the last five years, and the name and present address of each person with whom the child

has lived during that period;

(b) Whether you have participated as a party, a witness, or in any other capacity in any other

litigation, in this state or any other state, that concerned the allocation, between the

parents of the same child, of parental rights and responsibilities for the care of the child

and the designation of the residential parent and legal custodian of the child or that

otherwise concerned the custody of the same child;

in a court of this or any other state;

(d) Whether you know of any person who has physical custody of the child or claims to be a

parent of the child who is designated the residential parent and legal custodian of the

child or to have parenting time rights with respect to the child or to be a person other than

a parent of the child who has custody or visitation rights with respect to the child;

(e) Whether you previously have been convicted of or pleaded guilty to any criminal offense

involving any act that resulted in a child's being an abused child or a neglected child or

previously have been determined, in a case in which a child has been adjudicated an

abused child or a neglected child, to be the perpetrator of the abusive or neglectful act

that was the basis of the adjudication.

4. If the child's parent, guardian, or custodian acts to terminate the caretaker authorization affidavit

by delivering a written notice of negation, reversal, or disapproval of an action or decision of

yours or removes the child from your home and if you believe that the termination or removal is

not in the best interest of the child, you may, within fourteen days, file a complaint in the juvenile

court to seek custody. You may retain physical custody of the child until the fourteen-day period

elapses or, if you file a complaint, until the court orders otherwise.

To school officials:

1. This affidavit, properly completed and notarized, authorizes the child in question to attend school

in the district in which the grandparent who signed this affidavit resides and the grandparent is

authorized to provide consent in all school-related matters and to discuss with the school district

the child's educational progress. This affidavit does not preclude the parent, guardian, or

custodian of the child from having access to all school records pertinent to the child.

2. The school district may require additional reasonable evidence that the grandparent lives at the

address provided in item 5 of the affidavit.

3. A school district or school official that reasonably and in good faith relies on this affidavit has no

obligation to make any further inquiry or investigation.

4. The act of a parent, guardian, or custodian of the child to negate, reverse, or otherwise disapprove

an action or decision of the grandparent who signed this affidavit constitutes termination of this

affidavit. A parent, guardian, or custodian may negate, reverse, or disapprove a grandparent's

Caretaker Authorization Affidavit Page 3