"AFFIDAVIT OF ACCEPTANCE
BEFORE ME, the undersigned Notary Public, personally came and appeared: ________________________________________________________________________
___________________________________, individual(s) OR a representative of _____________________________ (name of agency or institution) who, being first duly sworn, did depose and state:
That affiant is a person of the full age of majority and resides at ___________________________________ (address of individual(s), agency, or institution) in ____________ Parish, Louisiana.
That affiant does knowingly and voluntarily accept physical custody OR legal custody of the person of the children (indicate one) of _________, _________, _________, _________ (name(s) of child(ren)) for the period of time ______________ (specify intended period) in accordance with the following terms and conditions:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________.
(may include provisions for support and/or visitation)
____________________________
AFFIANT
SWORN TO AND SUBSCRIBED BEFORE ME ON THIS THE ______ DAY OF _____________________,20___.
____________________________
NOTARY PUBLIC"
La. Ch.C. § 1516