INSTRUCTIONS A parent signs a Power of Attorney in front of a notary to give another person temporary parental control of their children. A Power of Attorney is not a court order. It may not be used to authorize another person to consent to your child’s marriage or adoption. A Power of Attorney expires after six months. If you want another Power of Attorney after six months, you may sign a new one. You may cancel, or “revoke”, the Power of Attorney at any time. See the Self-Help Center packet Power of Attorney Over a Minor Child: Revocation. STEP 1: (1) (2) (3) (4) (5) (6) (7) FILL OUT THE POWER OF ATTORNEY OVER A MINOR CHILD Enter your name and address. Enter the name and birthdate of each child you want included in the Power of Attorney. Enter the name and address of the person you want to have power of attorney. Check the box indicating whether you want to give that person full parental responsibility or only specific responsibilities. If you check “specific parental responsibilities”, list them. Enter the date when the Power of Attorney will begin. Enter the date, not more than six months later, when it will end. Read the Power of Attorney and make sure that you understand everything in it and that everything in it is true. Do not sign until you’re in front of a notary. Enter the witness’s name. The witness also must wait to sign until you’re in front of a notary. The witness may not be the person you want to have power of attorney or that person’s spouse or child. STEP 2: SIGN THE POWER OF ATTORNEY IN FRONT OF A NOTARY Take the following to a notary: [] [] [] The witness The original and one copy of the Power of Attorney Over a Minor Child Photo ID for the witness and yourself Notaries are at most banks or listed in the Yellow Pages. They usually charge a fee. Sign the original and the copy of the Power of Attorney in front of the notary and have the witness sign in front of the notary. STEP 3: GIVE A SIGNED POWER OF ATTORNEY TO THE OTHER PERSON Keep the other signed Power of Attorney for your records. STEP 4: MAKE COPIES OF THE POWER OF ATTORNEY Make copies of the Power of Attorney for each person or organization you deal with on behalf of the child. Show them the original, and give them the copy. Revised September 2006 Coconino County Law Library and Self-Help Center Forms American LegalNet, Inc. www.FormsWorkflow.com POWER OF ATTORNEY OVER A MINOR CHILD A.R.S. 14-5104 and 5501 (1) My Name: My Address: I am the natural parent of the following children. (2) Child’s Name: Birthdate: I authorize the following person to assume power of attorney over my children listed above, in accordance with A.R.S. 14-5104. (3) Name of Person Authorized: Address of Person Authorized: I further appoint the person named above as my true and lawful attorney for the purpose of performing the following responsibilities over my children listed above. (4) [ ] All parental responsibilities I might perform myself. [] Only the following specific parental responsibilities: and expire, , unless I revoke it (5) This Power of Attorney will begin on not more than six months later, on earlier. I, the principal, sign my name to this power of attorney, and, being first duly sworn, do declare to the undersigned authority that I sign and execute this instrument as my power of attorney and that I sign it willingly, that I execute it as my free and voluntary act for the purposes expressed in it and that I am at least 18 years old, of sound mind, and under no constraint or undue influence. (6) Parent’s Signature: State of Arizona County of Subscribed and sworn before me this date: Seal: Page 1 of 2 Revised September 2006 ) ) ) by: Notary Public: Notary Expiration Date: Coconino County Law Library and Self-Help Center Forms American LegalNet, Inc. www.FormsWorkflow.com (7) Witness’s Name: I, the witness, sign my name to the foregoing power of attorney being first duly sworn and do declare to the undersigned authority that the principal signs and executes this instrument as his/her power of attorney and that he/she signs it willingly and that I, in the presence and hearing of the principal, sign this power of attorney as witness to the principal's signing and that to the best of my knowledge the principal is at least 18 years old, of sound mind, and under no constraint or undue influence. Witness’s Signature: State of Arizona County of Subscribed and sworn before me this date: Seal: Page 2 of 2 Revised September 2006 ) ) ) by: Notary Public: Notary Expiration Date: Coconino County Law Library and Self-Help Center Forms American LegalNet, Inc. www.FormsWorkflow.com