Microsoft Word - POWER+OF+ATTORNEY1.doc

POWER OF ATTORNEY

I, the undersigned, residing at

, in

the county of

, state of

hereby appoint the child's grandparent,

residing at

in the county of

Franklin , in the state of Ohio, with whom the child of whom

I am the parent,

guardian, or custodian is residing, my attorney in fact to exercise any and all of my rights and

responsibilities regarding the care, physical custo dy, and control of the child,

, born

, having social security number (optional)

, except my authority to consent to marriage or ado ption of the

child

, and to perform all acts

necessary in the execution of the rights and respon sibilities hereby granted, as fully as I might do

if personally present. The rights I am transferring under this power of attorney include the ability

to enroll the child in school, to obtain from the s chool district educational and behavioral

information about the child, to consent to all scho ol-related matters regarding the child, and to

consent to medical, psychological, or dental treatm ent for the child. This transfer does not affect

my rights in any future proceedings concerning the custody of the child or the allocation of the

parental rights and responsibilities for the care o f the child and does not give the attorney in fact

legal custody of the child. This transfer does not terminate my right to have regular contact with

the child.

I hereby certify that I am transferring the rights and responsibilities designated in this power of

attorney because one of the following circumstances exists:

(1) I am: (a) Seriously ill, incarcerated or about

to be incarcerated, (b) Temporarily unable to

provide financial support or parental guidance to t he child, (c) Temporarily unable to provide

adequate care and supervision of the child because

of my physical or mental condition, (d)

Homeless or without a residence because the current

residence is destroyed or otherwise

uninhabitable, or (e) In or about to enter a reside ntial treatment program for substance abuse;

(2) I am a parent of the child, the child's other p arent is deceased, and I have authority to execute

the power of attorney; or

(3) I have a well-founded belief that the power of attorney is in the child's best interest.

I hereby certify that I am not transferring my righ ts and responsibilities regarding the child for

the purpose of enrolling the child in a school or s chool district so that the child may participate in

the academic or interscholastic athletic programs p rovided by that school or district.

I understand that this document does not authorize

a child support enforcement agency to

redirect child support payments to the grandparent

designated as attorney in fact. I further

understand that to have an existing child support o rder modified or a new child support order

issued administrative or judicial proceedings must be initiated.

If there is a court order naming me the residential parent and legal custodian of the child who is

the subject of this power of attorney and I am the

sole parent signing this document, I hereby

certify that one of the following is the case:

(1) I have made reasonable efforts to locate and pr ovide notice of the creation of this power of

attorney to the other parent and have been unable t o locate that parent;

(2) The other parent is prohibited from receiving a notice of relocation; or

(3) The parental rights of the other parent have be en terminated by order of a juvenile court.

This POWER OF ATTORNEY is valid until the occurrenc e of whichever of the following

events occurs first: (1) one year elapses following the date this POWER OF ATTORNEY is

notarized; (2) I revoke this POWER OF ATTORNEY in w riting; (3) the child ceases to reside

with the grandparent designated as attorney in fact ; (4) this POWER OF ATTORNEY is

terminated by court order; (5) the death of the chi ld who is the subject of the power of attorney;

or (6) the death of the grandparent designated as t he attorney in fact.

WARNING: DO NOT EXECUTE THIS POWER OF ATTORNEY IF ANY

STATEMENT MADE IN THIS INSTRUMENT IS UNTRUE. FALSIFICATION IS A

CRIME UNDER SECTION 2921.13 OF THE REVISED CODE, PUNISHABLE BY THE

SANCTIONS UNDER CHAPTER 2929. OF THE REVISED CODE, INCLUDING A

TERM OF IMPRISONMENT OF UP TO 6 MONTHS, A FINE OF UP TO $1,000, OR

BOTH.

Witness my hand this

day of

, 20

Parent/Custodian/Guardian’s signature

Parent’s signature

Grandparent designated as attorney in fact

State of Ohio

)

) ss:

County of

)

Subscribed, sworn to, and acknowledged before me th is

day of

Notary Public

NOTICES:

A power of attorney may be executed only if one of

the following circumstances

exists: (1) The parent, guardian, or custodian of t he child is: (a) Seriously ill,

incarcerated or about to be incarcerated; (b) Tempo rarily unable to provide financial

support or parental guidance to the child; (c) Temp orarily unable to provide adequate

care and supervision of the child because of the pa rent's, guardian's, or custodian's

physical or mental condition; (d) Homeless or witho ut a residence because the current

residence is destroyed or otherwise uninhabitable; or (e) In or about to enter a

residential treatment program for substance abuse; (2) One of the child's parents is

deceased and the other parent, with authority to do so, seeks to execute a power of

attorney; or (3) The parent, guardian, or custodian has a well-founded belief that the

power of attorney is in the child's best interest.

The signatures of the parent, guardian, or custodia n of the child and the grandparent

designated as the attorney in fact must be notarize d by an Ohio notary public.

A parent, guardian, or custodian who creates a powe r of attorney must notify the

parent of the child who is not the residential pare nt and legal custodian of the child

unless one of the following circumstances applies: (a) the parent is prohibited from

receiving a notice of relocation in accordance with section 3109.051 of the Revised

Code of the creation of the power of attorney; (b)

the parent's parental rights have

been terminated by order of a juvenile court pursua nt to Chapter 2151. of the Revised

Code; (c) the parent cannot be located with reasona ble efforts; (d) both parents are

executing the power of attorney. The notice must be sent by certified mail not later

than five days after the power of attorney is creat ed and must state the name and

address of the person designated as the attorney in fact.

A parent, guardian, or custodian who creates a powe r of attorney must file it with the

juvenile court of the county in which the attorney in fact resides, or any other court

that has jurisdiction over the child under a previo usly filed motion or proceeding. The

power of attorney must be filed not later than five days after the date it is created and

be accompanied by a receipt showing that the notice

of creation of the power of

attorney was sent to the parent who is not the resi dential parent and legal custodian by

certified mail.

A parent, guardian, or custodian who creates a seco nd or subsequent power of

attorney regarding a child who is the subject of a prior power of attorney must file the

power of attorney with the juvenile court of the co unty in which the attorney in fact

resides or any other court that has jurisdiction ov er the child under a previously filed

motion or proceeding. On filing, the court will sch edule a hearing to determine

whether the power of attorney is in the child's bes t interest.

This power of attorney does not affect the rights o f the child's parents, guardian, or

custodian regarding any future proceedings concerni ng the custody of the child or the

allocation of the parental rights and responsibilit ies for the care of the child and does

not give the attorney in fact legal custody of the child.

A person or entity that relies on this power of att orney, in good faith, has no

obligation to make any further inquiry or investiga tion.

This power of attorney terminates on the occurrence of whichever of the following

occurs first: (1) one year elapses following the da te the power of attorney is notarized;

(2) the power of attorney is revoked in writing by

the person who created it; (3) the

child ceases to live with the grandparent who is th e attorney in fact; (4) the power of

attorney is terminated by court order; (5) the deat h of the child who is the subject of

the power of attorney; or (6) the death of the gran dparent designated as the attorney in

fact.

If this power of attorney terminates other than by the death of the attorney in fact, the

grandparent who served as the attorney in fact shal l notify, in writing, all of the

following:

(a) Any schools, health care providers, or health insur ance coverage provider with

which the child has been involved through the grand parent;

(b) Any other person or entity that has an ongoing rela tionship with the child or

grandparent such that the other person or entity wo uld reasonably rely on the

power of attorney unless notified of the terminatio n;

(d) The parent who is not the residential parent and le gal custodian of the child who

is required to be given notice of its creation. The

grandparent shall make the

notifications not later than one week after the dat e the power of attorney

terminates.

If this power of attorney is terminated by written

revocation of the person who

created it, or the revocation is regarding a second or subsequent power of attorney, a

copy of the revocation must be filed with the court with which that power of attorney

was filed.

Additional information:

To the grandparent designated as attorney in fact:

If the child stops living with you, you are require d to notify, in writing, any school,

health care provider, or health care insurance prov ider to which you have given this

power of attorney. 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 person or

entity would reasonably rely on the power of attorn ey unless notified. The

notification must be made not later than one week a fter the child stops living with

you.

You must include with the power of attorney the fol lowing information:

(a) The child's present address, the addresses of the p laces where the child has lived

within the last five years, and the name and presen t address of each person with

whom the child has lived during that period;

(b) Whether you have participated as a party, a witness , or in any other capacity in

any other litigation, in this state or any other st ate, that concerned the allocation,

between the parents of the same child, of parental

rights and responsibilities for

the care of the child and the designation of the re sidential parent and legal

custodian of the child or that otherwise concerned the custody of the same child;

pending in a court of this or any other state;

(d) Whether you know of any person who has physical cus tody of the child or claims

to be a parent of the child who is designated the r esidential parent and legal

custodian of the child or to have parenting time ri ghts with respect to the child 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 convicted of or pl eaded 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 chi ld, to be the perpetrator of the

abusive or neglectful act that was the basis of the adjudication.

To school officials:

Except as provided in section 3313.649 of the Revis ed Code, this power of attorney,

properly completed and notarized, authorizes the ch ild in question to attend school in

the district in which the grandparent designated as attorney in fact resides and that

grandparent is authorized to provide consent in all

school-related matters and to

obtain from the school district educational and beh avioral information about the child.

This power of attorney does not preclude the parent , guardian, or custodian of the

child from having access to all school records pert inent to the child.

The school district may require additional reasonab le evidence that the grandparent

lives in the school district.

A school district or school official that reasonabl y and in good faith relies on this

power of attorney has no obligation to make any fur ther inquiry or investigation.

To health care providers:

A person or entity that acts in good faith reliance on a power of attorney to provide

medical, psychological, or dental treatment, withou t actual knowledge of facts

contrary to those stated in the power of attorney, 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 power of at torney is completed and the

signatures of the parent, guardian, or custodian of the child and the grandparent

designated as attorney in fact are notarized.

The decision of a grandparent designated as attorne y in fact, based on a power of

attorney, shall be honored by a health care facilit y or practitioner, school district, or

school official.