(b) The kinship caregiver's affidavit shall be substantially in the following form: "KINSHIP CAREGIVER'S AFFIDAVIT
Use of this affidavit is authorized by O.C.G.A. Section 20-1-16.
INSTRUCTIONS: Please print clearly.
I hereby certify that the child named below lives in my home and I am 18 years of age or older.
1. Name of child: __________________2. Child's date of birth: __________________3. My full name (kinship caregiver giving authorization): __________________4. My home address: __________________5. [ ] I am a kinship caregiver.6. I have assumed kinship caregiver status because of one or more of the following circumstances (check at least one): [ ] A parent being unable to provide care due to the death of the other parent;
[ ] A serious illness or terminal illness of a parent;
[ ] The physical or mental condition of the parent or the child such that proper care and supervision of the child cannot be provided by the parent;
[ ] The incarceration of a parent;
[ ] The loss or uninhabitability of the child's home as the result of a natural disaster;
[ ] A period of active military duty of a parent exceeding 24 months; or
[ ] I am unable to locate a parent or parents at this time to notify them of my intended authorization because (list reasons):
__________________.
7. Names of parent(s) or legal custodian(s): __________________8. Address of parent(s) or legal custodian(s): __________________9. Phone numbers and email addresses of parent(s) or legal custodian(s):10. Kinship caregiver's date of birth: __________________11. Kinship caregiver's State of Georgia driver's license number or identification card number: __________________ WARNING: DO NOT SIGN THIS FORM IF ANY OF THE STATEMENTS ABOVE ARE INCORRECT OR YOU WILL BE COMMITTING A CRIME PUNISHABLE BY A FINE, IMPRISONMENT, OR BOTH.
I recognize that if I knowingly and willfully make a false statement in this affidavit, I will be guilty of the crime of false swearing.
__________________
(Kinship caregiver's signature)
__________________
(Kinship caregiver's printed name)
Sworn to and subscribed
before me this __________________
day of __________________, __________________.
Notary public (SEAL)
My commission expires: __________________.
NOTICES:
1. This declaration does not affect the rights of the named child's parent or legal guardian regarding the care, custody, and control of the child and does not mean that the kinship caregiver has legal custody of the child.2. A person who relies on this affidavit has no obligation to make any further inquiry or investigation.3. This affidavit is not valid for more than one year after the date on which it is executed.ADDITIONAL INFORMATION:
TO KINSHIP CAREGIVERS:
1. If the child stops living with you for a period of more than 30 days, you are required to provide notice not later than 30 days after such period to anyone to whom you have given this affidavit as well as anyone of whom you have actual knowledge who received the affidavit from a third party.2. If you do not have the information in item 11 of the affidavit (State of Georgia driver's license or identification card), you must provide another form of identification, such as your social security number.TO SCHOOL OFFICIALS:
The school system may require additional reasonable evidence that the kinship caregiver resides at the address provided in item 4 of the affidavit.
TO HEALTH CARE PROVIDERS AND HEALTH CARE SERVICE PLANS:
1. No person who acts in good faith reliance upon a kinship caregiver's affidavit to render educational services or medical services directly related to academic enrollment or any curricular or extracurricular activities, without actual knowledge of facts contrary to those stated in the affidavit, shall be subject to criminal prosecution or civil liability to any person, or subject to any professional disciplinary action, for such reliance if the applicable portions of the form are completed.2. This affidavit does not confer dependency for health care coverage purposes."