Statutory Form for Power of Attorney to Delegate Parental or Legal Custodian Powers
(Full name of minor child) | (Date of birth) | |
(Full name of minor child) | (Date of birth) | |
(Full name of minor child) | (Date of birth) |
who is/are minor children.
(Full name of attorney-in-fact) | |
(Street address, city, state and zip code of attorney-in-fact) | |
(Home phone, work phone and cell phone of attorney-in-fact) as the attorney-in-fact of each minor child named above. |
OR
____________________
[If Section 3(b) is completed, Section 3(a) does not apply.]
This delegation shall not include the power or authority to consent to: marriage or adoption of the child, performing or inducing an abortion on or for the child, or the termination of parental rights to the child.
____________________
[Complete either 4(a) or 4(b)]
OR
[Complete either 4(a) or 4(b)]
By: (Parent/Legal Custodian signature)
(Attorney-in-fact signature)
I, ____________________ of (Agency)____________________, do hereby certify that I have properly vetted the proposed designated attorney-in-fact as required under Section 93-31-3(1)(d), Mississippi Code of 1972, and find no criminal or child abuse or neglect history.
(Agency representative signature)
Name of facilitating agency
State of ____________________
County of ____________________
ACKNOWLEDGEMENT
Before me, the undersigned, a Notary Public, in and for said county and state on this day____________________ of ____________________, 20____________________, personally appeared __________(Name of facilitating agency and person signing as facilitator), __________(Name of Parent/Legal Custodian) and __________(Name of Attorney-in-fact), known to me to be the persons who executed this instrument and who acknowledged to me that each executed the same as his or her free and voluntary act and deed for the uses and purposes set forth in the instrument.
Witness my hand and official seal the day and year above written.
(Signature of notarial officer)
(Seal, if any)
(Title and Rank)
My commission expires:____________________"
Affidavit of Custodial Parent
STATE OF ____________________
COUNTY OF ____________________
I hereby certify that I am the custodial parent of the child(ren)_who are the subject of the power of attorney to which this affidavit is attached. I further certify that the location of the noncustodial parent, ____________________ is unknown to me or that the identity of the father is unknown to me (insert here if the father is unknown) ____________________ or that the noncustodial parent is unavailable (state here the reason unavailable): ____________________.
SO SWORN, this the ____________________ day of ____________________, 20____________________
Custodial Parent
SWORN TO AND SUBSCRIBED BEFORE ME, the undersigned authority in and for the aforementioned jurisdiction, the within named person who first presented proof of identity.
THIS, the ____________________ day of ____________________, 20____________________.
NOTARY PUBLIC
My commission expires: ____________________
Statutory Form for Revocation of Power of Attorney to Delegate Parental or Legal Custodial Powers
(Full name of minor child) | (Date of birth) |
(Full name of minor child) | (Date of birth) |
(Full name of minor child) | (Date of birth) |
who is/are minor children.
(Full name of attorney-in-fact and DOB)
(Street address, city, state and zip code of attorney-in-fact)
ACKNOWLEDGEMENT
Before me, the undersigned, a Notary Public, in and for said county and state on this day____________________ of ____________________, 20____________________, personally appeared __________(Name of Parent/Legal Custodian), known to me to be the person who executed this instrument and who acknowledged to me that he or she executed this instrument as his or her free and voluntary act and deed for the uses and purposes set forth in the instrument.
Witness my hand and official seal the day and year above written.
(Signature of notarial officer)
(Signature of notarial officer)
(Seal, if any)
(Title and Rank)
My commission expires:____________________"
Miss. Code § 93-31-5