Miss. Code. tit. 18, pt. 6, ch. 1, 18-6-1-D, 18-6-1-D-XII, app 18-6-1-D-XII-P
We, the undersigned Resource Parent(s), Relative/Non-Relative, and _________________ county
Department of Human Services, believing that it is in the best interest of
__________________________________________________________
That he/she be allowed to remain in the home of _____________________________________ and be raised as a member of the family group until said child reaches adulthood, do hereby agree and covenant the following:
The intent of this Agreement is to provide continued care for the above named child in the same home in order to restore and create a permanent and stable foundation for said child.
The Resource Parent/Relative/Non-Relative of said child agree to act as the primary parental figures of said child until he/she becomes and adult, marries, or is otherwise freed from minority.
Further, we expressly acknowledge the intent of this Agreement and hereby agree that we will not seek the removal of said child from our home except under the most serious and emergency circumstances, acknowledging our willingness to accept legal, physical and financial responsibility if Durable Legal Custody is accepted and ordered by the Court.
We further acknowledge that the option of adoption was presented and discussed and determined not to be in the best interest of said child and agree and understand we are accepting legal and physical custody of this child and that any board payment and/or Medicaid being received through MDHS will end at the time the court finalizes custody. We understand that DLC only becomes effective by order of the court.
WITNESS OUR SIGNATURES:
_____________________________________________________________________
Resource Father/Relative/Non-RelativeResource Mother/Relative/Non-Relative
______________________________________________________________________
COR ASWSDateCOS ASWSDate
_______________________________________________________
Licensure SpecialistDate
_______________________________________________________
Adoption SpecialistDate
Miss. Code. tit. 18, pt. 6, ch. 1, 18-6-1-D, 18-6-1-D-XII, app 18-6-1-D-XII-P