TEMPORARY GUARDIANSHIP AFFIDAVIT

I , ${input_22_16} , residing at ${input_22_17_1} , ${input_22_17_3} , ${input_22_17_4} ${input_22_17_5} , declare that the ${input_22_14} of the minor child or children listed below:

Name

Date of Birth

Gender

${input_22_9}

${input_22_10}

${input_22_11}

CAUSE FOR TEMPORARY GUARDIANSHIP

In order to properly care for ${input_22_9} , ${input_22_29} will ensure the nutrition, health, shelter, and physical safety of the child.

The need for temporary guardianship arose due to "legal guardian" ${input_22_3}

I hereby appoint and duly authorize ${input_22_29} , residing at ${input_22_30_1} , ${input_22_30_3} , ${input_22_30_4} ${input_22_30_5} , to exercise concurrently any and all rights and responsibilities, and to perform any and all acts deemed necessary and appropriate for a temporary Guardian of a minor child or children including the following:

HEALTH AND EMERGENCY MEDICAL CARE

EDUCATION

TRAVEL

${input_22_86}

The temporary Guardian is NOT authorized to do or perform the following:

hereby declare and certify that the following statements are accurate to the best of knowledge:

-   That there are no court orders currently in effect that would prohibit me from exercising or conferring the aforementioned rights and authority upon the herein named Temporary Guardian.(In the event that the Authorizing Party is a court appointed legal guardian or custodian to the aforementioned minor child or children, then a copy of said court order for such appointed should be attached hereto.)

-   That I freely and knowingly confer the above mentioned rights and responsibilities in order to provide for the minor child or children and not as a result of pressure, threats or payment by any person or agency.

-   In the event that I wish to amend or revoke this affidavit, I will provide a copy of the amended affidavit or revocation to all parties to whom I provided a copy of the original affidavit.

Temporary Guardianship shall become effective on ${input_22_36} and shall remain in full force and effect until ${input_22_37} , or until such time as , as the appointing ${input_22_14} , notify the designated temporary guardian(s) in writing that this document has been amended or revoked.

BE IT KNOWN , under the penalty of perjury, hereby affirm that the above statements are true and correct to the best of my knowledge.

Signature:_____________________	Date:_____________________
Authorizing ${input_22_14} : ${input_22_16}
Telephone Number: ${input_22_90}

WITNESSES TO AUTHORIZING PARTY SIGNATURE

(To be signed by persons over the age of 18 who are not the designated guardian/agent)

NOTARIZATION OF AUTHORIZING PARTY'S SIGNATURE

STATE OF ${input_22_78}                               )

COUNTY OF ${input_22_79}                          )

On this date, _________________, before me, the undersigned notary public, ${input_22_16} and ${input_22_29} personally appeared, and provided satisfactory evidence of identification (Driver's License; Passport; etc.), to be the person whose name is signed on the preceding document, and swore under the penalty of perjury that the foregoing statements are true.

Notary Signature:  ____________________________

My Commission Expires:  ______________________

TEMPORARY GUARDIAN ACKNOWLEDGMENT

, ${input_22_29} , declare that at least 18 years of age.understand that may, without obtaining further consent from a parent, legal custodian, or legal guardian of the minor child or children, exercise concurrent power relative to the minor child or children, except those powers prohibited above.However, may not knowingly make a decision that conflicts with the decision of the minor child or children's parent, legal guardian, or legal custodian.

understand that, if the affidavit is amended or revoked, must provide the amended affidavit or revocation to all parties to whom have provided this affidavit prior to further exercising any rights or responsibilities under the affidavit.

Under penalty of perjury, hereby affirm that the above statements are true and correct to the best of knowledge.

___________________________________ Signature:	_____________________ Date:
Temporary Guardian(s): ${input_22_29} Telephone Number: ${input_22_92}