Arkansas Power Of Attorney For A Child Form Page 2
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2do or cause to be done by virtue of this Power-of-Attorney and the rights and
powers herein granted.
(If you want a revocation date in advance)
7. This Power of Attorney appointing ________________________ (Name of
Agent) as my agent and attorney in fact performing and acting for me in a
parental capacity for my child, __________________________ (Child’s Name),
will be revoked automatically on ________________________ (Date of
Revocation).
8. It is not my intention to relinquish my parental rights in and to my child.
IN TESTIMONY WHEREOF, I have hereunto set my hand this
day of
, 20 .
(NAME OF PARENT)
STATE OF ARKANSAS )
) ss
COUNTY OF
)
On this
day of
, 20
, before me personally came parent, to me
known to be the person described in and who executed the foregoing instrument, and
acknowledged that he/she executed the same as a free act and deed, and that (NAME OF
PARENT) is the mother/father of said children.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this
day
of
, 20
.
NOTARY PUBLIC
My Commission Expires:
(S E A L)
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