Power Of Attorney Delegating Parental Power Page 4

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WITNESSING OF SIGNATURE(S) (OPTIONAL)
State of ________________________________; County of __________________________________
This document was signed before me on (day/month/year) ___________________ by (name(s) of
parent(s)) _________________________________________________________________________
______________________________________
Signature of notary public
My commission expires: __________________
STATEMENT OF AGENT
I, ____________________________________ , understand that _____________________________
(name and address of agent)
(name(s) of parent(s))
has (have) delegated to me the powers specified in this Power of Attorney regarding the care and
custody of ________________________________________________________________________.
(name(s) of child(ren))
I further understand that this Power of Attorney may be revoked in writing at any time by a parent
who has legal custody of ____________________________________________________________.
(name(s) of child(ren)).
I hereby declare that I have read this Power of Attorney, understand the powers delegated to me by
this Power of Attorney, am fit, willing, and able to undertake those powers, and accept those
powers.
______________________________________
__________________________
AGENT SIGNATURE
DATE
APPENDIX
Here the parent(s) may indicate where they may be located during the term of the Power of Attorney if
different from the address(es) set forth above.
I can be located at:
OR By contacting:
Address(es) ______________________________
Name __________________________________
Telephone _______________________________
Address ________________________________
E-mail address ___________________________
Phone _________________________________
E-mail address ___________________________
OR I cannot be located.
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