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CARETAKER AUTHORIZATION AFFIDAVIT

Use of this affidavit is authorized by sections 310

9.65 to 3109.73 of the Ohio Revised Code.

Completion of items 1-7 and the signing and notariz

ation of this affidavit is sufficient to

authorize the grandparent signing to exercise care,

physical custody, and control of the child who

is its subject, including authority to enroll the c

hild in school, to discuss with the school district

the child's educational progress, to consent to all

school-related matters regarding the child, and

to consent to medical, psychological, or dental tre

atment for the child.

The child named below lives in my home, I am 18 yea

rs of age or older, and I am the child's

grandparent.

1. Name of child:

2. Child's date and year of birth:

3. Child's social security number (optional):

4. My name:

5. My home address:

6. My date and year of birth:

7. My Ohio driver's license number or identificati

on card number:

8. Despite having made reasonable attempts, I am e

ither:

(a) Unable to locate or contact the child's

parents, or the child's guardian or custodian; or

(b) I am unable to locate or contact one of the ch

ild's parents and I am not required to

contact the other parent because paternity has not

been established; or

ld's parents and I am not required to

contact the other parent because there is a custody

order regarding the child and one of

the following is the case:

(i) The parent has been prohibited from receiving

notice of a relocation; or

(ii) The parental rights of the parent have been t

erminated.

9. I hereby certify that this affidavit is not bei

ng executed for the purpose of enrolling the child

in a school or school district so that the child ma

y participate in the academic or

interscholastic athletic programs provided by that

school or district.

I understand that this document does not authorize

a child support enforcement agency to

redirect child support payments. I further understa

nd that to have an existing child support

order modified or a new child support order issued

administrative or judicial proceedings

must be initiated.

WARNING: DO NOT SIGN THIS FORM IF ANY OF THE ABOVE

STATEMENTS

ARE INCORRECT. FALSIFICATION IS A CRIME UNDER SECTI ON 2921.13 OF THE

REVISED CODE, PUNISHABLE BY THE SANCTIONS UNDER CHA

PTER 2929. OF

THE REVISED CODE, INCLUDING A TERM OF IMPRISONMENT

OF UP TO 6

MONTHS, A FINE OF UP TO $1,000, OR BOTH.

I declare that the foregoing is true and correct:

Signed:

Date:

Grandparent

State of Ohio )

) ss:

County of

)

Subscribed, sworn to, and acknowledged before me th

day of

, 20

Notary Public

Notices:

1. The grandparent's signature must be notarized b

y an Ohio notary public.

2. The grandparent who executed this affidavit mus

t file it with the juvenile court of the county

in which the grandparent resides or any other court

that has jurisdiction over the child under a

previously filed motion or proceeding not later tha

n five days after the date it is executed.

3. A grandparent who executes a second or subseque

nt caretaker authorization affidavit

regarding a child who is the subject of a prior car

etaker authorization affidavit must file the

affidavit with the juvenile court of the county in

which the grandparent resides or any other

court that has jurisdiction over the child under a

previously filed motion or proceeding. On

filing, the court will schedule a hearing to determ

ine whether the caretaker authorization

affidavit is in the child's best interest.

4. This affidavit does not affect the rights of th

e child's parents, guardian, or custodian regarding

the care, physical custody, and control of the chil

d, and does not give the grandparent legal

custody of the child.

5. A person or entity that relies on this affidavi

t, in good faith, has no obligation to make any

further inquiry or investigation.

6. This affidavit terminates on the occurrence of

whichever of the following occurs first: (1) one

year elapses following the date the affidavit is no

tarized; (2) the child ceases to live with the

grandparent who signs this form; (3) the parent, gu

ardian, or custodian of the child acts to

negate, reverse, or otherwise disapprove an action

or decision of the grandparent who signed

this affidavit; or (4) the affidavit is terminated

by court order; (5) the death of the child who

is the subject of the affidavit; or (6) the death o

f the grandparent who executed the affidavit.

A parent, guardian, or custodian may negate, revers

e, or disapprove a grandparent's action or

decision only by delivering written notice of negat

ion, reversal, or disapproval to the

grandparent and the person acting on the grandparen

t's action or decision in reliance on this

affidavit.

If this affidavit terminates other than by the deat

h of the grandparent, the grandparent who

signed this affidavit shall notify, in writing, all

of the following:

(a) Any schools, health care providers, or health i

nsurance coverage provider with which the

child has been involved through the grandparent;

(b) Any other person or entity that has an ongoing

relationship with the child or grandparent

such that the person or entity would reasonably rel

y on the affidavit unless notified of the

termination;

r its creation.

The grandparent shall make the notifications not la

ter than one week after the date the

affidavit terminates.

7. The decision of a grandparent to consent to or

to refuse medical treatment or school

enrollment for a child is superseded by a contrary

decision of a parent, custodian, or guardian

of the child, unless the decision of the parent, gu

ardian, or custodian would jeopardize the

life, health, or safety of the child.

Additional information:

To caretakers:

1. If the child stops living with you, you are req

uired to notify, in writing, any school, health

care provider, or health care insurance provider to

which you have given this affidavit. You

are also required to notify, in writing, any other

person or entity that has an ongoing

relationship with you or the child such that the pe

rson or entity would reasonably rely on the

affidavit unless notified. The notifications must b

e made not later than one week after the

child stops living with you.

2. If you do not have the information requested in

item 7 (Ohio driver's license or identification

card), provide another form of identification such

as your social security number or medicaid

number.

3. You must include with the caretaker authorizati

on affidavit the following information:

(a) The child's present address, the addresses of t

he places where the child has lived within

the last five years, and the name and present addre

ss of each person with whom the child has

lived during that period;

(b) Whether you have participated as a party, a wit

ness, or in any other capacity in any other

litigation, in this state or any other state, that

concerned the allocation, between the parents of

the same child, of parental rights and responsibili

ties for the care of the child and the

designation of the residential parent and legal cus

todian of the child or that otherwise

concerned the custody of the same child;

ting proceeding concerning the child pending

in a court of this or any other state;

(d) Whether you know of any person who has ph

ysical custody of the child or claims to be a

parent of the child who is designated the residenti

al parent and legal custodian of the child or

to have parenting time rights with respect to the c

hild or to be a person other than a parent of

the child who has custody or visitation rights with

respect to the child;

(e) Whether you previously have been convicte

d of or pleaded guilty to any criminal offense

involving any act that resulted in a child being an

abused child or a neglected child or

previously have been determined, in a case in which

a child has been adjudicated an abused

child or a neglected child, to be the perpetrator o

f the abusive or neglectful act that was the

basis of the adjudication.

To school officials:

1. This affidavit, properly completed and notarize

d, authorizes the child in question to attend

school in the district in which the grandparent who

signed this affidavit resides and the

grandparent is authorized to provide consent in all

school-related matters and to discuss with

the school district the child's educational progres

s. This affidavit does not preclude the

parent, guardian, or custodian of the child from ha

ving access to all school records pertinent

to the child.

2. The school district may require additional reas

onable evidence that the grandparent lives at

the address provided in item 5.

3. A school district or school official that reaso

nably and in good faith relies on this affidavit ha

no obligation to make any further inquiry or invest

igation.

4. The act of a parent, guardian, or custodian of

the child to negate, reverse, or otherwise

disapprove an action or decision of the grandparent

who signed this affidavit constitutes

termination of this affidavit. A parent, guardian,

or custodian may negate, reverse, or

disapprove a grandparent's action or decision only

by delivering written notice of negation,

reversal, or disapproval to the grandparent and the

person acting on the grandparent's action

or decision in reliance on this affidavit.

To health care providers:

1. A person or entity that acts in good faith reli

ance on a CARETAKER AUTHORIZATION

AFFIDAVIT to provide medical, psychological, or den

tal treatment, without actual

knowledge of facts contrary to those stated in the

affidavit, is not subject to criminal liability

or to civil liability to any person or entity, and

is not subject to professional disciplinary

action, solely for such reliance if the applicable

portions of the form are completed and the

grandparent's signature is notarized.

2. The decision of a grandparent, based on a CARET

AKER AUTHORIZATION AFFIDAVIT,

shall be honored by a health care facility or pract

itioner, school district, or school official

unless the health care facility or practitioner or

educational facility or official has actual

knowledge that a parent, guardian, or custodian of

a child has made a contravening decision

to consent to or to refuse medical treatment for th

e child.

3. The act of a parent, guardian, or custodian of