Caregiver Authorization Affidavit Form - Metro Housing Boston (Page 2 of 2) in pdf

2. WITNESSES TO AUTHORIZING PARTY SIGNATURE

(To be signed by persons over the age of 18 who are not the designated caregiver.)

_______________________________

Witness #1 Signature

Witness #2 Signature

_______________________________

Printed Name, Address and Telephone

_______________________________

3. NOTARIZATION OF AUTHORIZING PARTY’S SIGNATURE

Commonwealth of Massachusetts

______________, ss

On this date, _______________, before me, the undersigned notary public, personally appeared

_________________________________________, proved to me through satisfactory evidence of

identification, which was _________________________________, to be the person whose name is signed

on the preceding document, and swore under the pains and penalties of perjury that the foregoing

statements are true.

Signature and seal of notary:

_____________________________

Printed name of notary:

_____________________________

My commission expires:

_____________________________

4. CAREGIVER ACKNOWLEDGMENT

, ______________________________________, am at least 18 years of age and the above child(ren)

currently reside with me at _____________________________________________. I am the

_______________________.

children’s (state your relationship to the child) ________

I understand that I may, without obtaining further consent from a parent, legal custodian or legal

guardian of the child(ren), exercise concurrent rights and responsibilities relative to the

education and health care of the child(ren), except those rights and responsibilities prohibited

above. However, I may not knowingly make a decision that conflicts with the decision of the

child(ren)’s parent, legal guardian or legal custodian.

I understand that, if the affidavit is amended or revoked, I must provide the amended affidavit or

revocation to all parties to whom I have provided this affidavit prior to further exercising any

rights or responsibilities under the affidavit.

I hereby affirm that the above statements are true, under pains and penalties of perjury.

Signature of caregiver:

_____________________________

Printed name:

_____________________________

Telephone Number:

_____________________________

Date:

_____________________________

Caregiver Authorization Affidavit Form - Metro Housing Boston Page 2