"Power of Attorney for Temporary Delegation of Parental or Legal Custody and Care
__________________________________________ _______________
(Full name of minor child) (Date of birth)
__________________________________________ _______________
(Full name of minor child) (Date of birth)
__________________________________________ _______________
(Full name of minor child) (Date of birth)
_______________________________________________________________________
(Street address, city, state, and zip code of Attorney-in-fact)
_______________________________________________________________________
(Home phone of Attorney-in-fact)____________________________________________
(Work phone of Attorney-in-fact)____________________________________________ as the Attorney-in-fact of each minor child named above.
OR
In the event that Section 4 is completed, Section 3 does not apply.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
This delegation shall not include the power or authority to consent to marriage or adoption of the child, the performance or inducement of an abortion on or for the child, or the termination of parental rights to the child.
beginning _____________________, 20___,
and ending _____________________, 20__.
I reserve the right to revoke this authority at any time.
OR
In the event Section 6 is completed and valid, Section 5 does not apply.
(Parent/Legal Guardian signature)
_____________________________________________
(Attorney-in-fact signature)
County of __________________
ACKNOWLEDGMENT
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 Guardian)
_________________________
(Name of Attorney-in-fact),
to me known to be the identical persons who executed this instrument and 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 notary public)
My commission expires: _________________."
KRS 403.353
Effective: June 29, 2021
Amended 2021 Ky. Acts ch. 94, sec. 35, effective June 29, 2021. -- Created 2016 Ky. Acts ch. 107, sec. 2, effective July 15, 2016.