Power Of Attorney {DR-615}

Case No. ___________________ POWER OF ATTORNEY I, the undersigned, residing at __________________ ____________________________, in the county of ___________, state of ____________ , hereby appoint the childs grandparent, ________________________, residing at ____________________________________________, in the county of _____________, 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 rega rding the care, physical custody, and control of the child, ________________________, born _____________, having social security number (optional)_______________, except my authority to consent to marriage or adoption of the child ____________________________and to perform all acts necessary in the execution of the rights and responsibilities hereby granted, as fully as I might do if personally present. The rights I am transfer ring under this power of attorney include the ability to enroll the child in school, to obtain from the school district educational and behavioral information about the child, to consent to all school-related matters regarding the child, and to consent to medical, psychological, or dental treatment 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 res ponsibilities for the care of 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 res ponsibilities 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 the 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 residential treatment program for substance abuse; (2) I am a parent of the child, the childs other parent 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 childs best interest. I hereby certify that I am not transferring my rights and responsibilities regarding the child for the purpose of enrolling the child in a school or school district so that the child may 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 to the grandparent designated as attorney in fa ct. I further understand that to have an existing child support order 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 provide notice of the creation of this power of attorney to the other parent and have been unable to 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 been terminated by order of a juvenile court. This POWER OF ATTORNEY is valid until the occurrence of whichever of the following events occurs first: (1) one year elapses following the date this POWER OF ATTO RNEY is notarized; (2) I revoke this POWER OF ATTORNEY in writing; (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 child who is the subject of the power of attorney; or (6) the death of the grandpar ent designated as the attorney in fact. American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2WARNING: DO NOT EXECUTE THIS POWER OF ATTORNEY IF ANY STATEM ENT 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/Guardians signature ________________________________ Parents signature ________________________________ Grandparent designated as attorney in fact State of Ohio ) ) ss: County of Clermont ) Subscribed, sworn to, and acknowledged before me this ______ day of ______________, 20_______ ___________________________________ 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 the child is: (a) Seriously ill, incarcerated or about to be incarcerated; (b) Temporarily unable to provide financial support or parental guidance to the child; (c) Temporarily unable to provide adequate care and supervision of the child because of the parents, guar dians, or custodians 1. 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 residential treatment program for substance abuse; (2) One of the childs parents is dece ased 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 childs best interest. The signatures of the parent, guardian, or custodian of the child and the grandparent designated as the 2. attorney in fact must be notarized by an Ohio notary public. A parent, guardian, or custodian who cr eates a power of attorney must notify the parent of the child who is not the residential parent 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 pare