Case No. _________________ CARETAKER AUTHORIZATION AFFIDAVIT Completion of items 1-7 and the signing and notarization of this affidavit is sufficient to authorize the grandparent signing to exercise care, physical custody, and control of the child who is its subject, including authority to enroll the child in school, to discuss with the school district the childs educational progress, to consent to all school-related matters regarding the child, and to consent to medical, psychological, or dental treatment for the child. The child named below lives in my home, I am 18 years of age or older, and I am the childs grandparent. 1. Name of child: __________________________ 2. Childs date and year of birth: _____/_____/_____ 3. Childs social security number (optional): ______-_______-______ 4. My name: ______________________________________________ 5. My home address: ____________________________________________________________________ 6. My date and year of birth: _____/_____/_____ 7. My Ohio drivers license number or identification card number: _________________ 8. Despite having made reasonable attempts, I am either: (a) Unable to locate or contact the childs parents, or the childs guardian or custodian; or (b) I am unable to locate or contact one of the childs parents and I am not required to contact the other parent because paternity has not been established; or (c) I am unable to locate or contact one of the childs parents and I am not required to contact the other parent because there is a custody order regarding the child and one of the following is the case: (i) The parent has been prohibited from receiving notice of a relocation; or (ii) The parental rights of the parent have been terminated. I hereby certify that this affidavit is not being executed for the purpose of enrolling the child in a school or 9. school district so that the child may participate in the ac ademic 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. I further understand that to have an existing child support order modified or a new child support order issued administrative or j udicial proceedings must be initiated. WARNING: DO NOT SIGN THIS FORM IF ANY OF THE ABOVE STATEMENTS ARE INCORRECT. 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. I declare that the foregoing is true and correct: Signed:_____________________________ Date:________________________ Grandparent State of Ohio ) ) ss: County of Clermont ) Subscribed, sworn to, and acknowledged before me this ________day of _________________, 20____ ____________________________________ American LegalNet, Inc. Notary Public www.USCourtForms.com>>>> 2 Notices: 1. The grandparents signature must be notarized by an Ohio notary public. The grandparent who executed this affidavit must file it with the juvenile court of the county in which the 2. grandparent resides or any other court that has jurisdic tion over the child under a previously filed motion or proceeding not later than five days after the date it is executed. A grandparent who executes a second or subsequent ca retaker authorization affidavit regarding a child who is the subject of a prior caretaker authorization affidavit must file the affidavit with the juvenile court of the 3. county in which the grandparent resides or any other court that has jurisdiction over the child under a previously filed motion or proceeding. On filing, the court will schedule a hearing to determine whether the caretaker authorization affidavit is in the childs best interest. This affidavit does not affect the rights of the childs parents, guardian, or custodian regarding the care, 4. physical custody, and control of the child, and does no t give the grandparent legal custody of the child. A person or entity that relies on this affidavit, in good faith, has no obligation to make any further inquiry or 5. investigation. This affidavit terminates on the occurrence of whichever of the following occurs first: (1) one year elapses following the date the affidavit is notarized; (2) the child ceases to live with the grandparent who signs this form; (3) the parent, guardian, or custodian of the child acts to negate, reverse, or otherwise disapprove an 6. action or decision of the grandparent who signed this a ffidavit; or (4) the affidavit is terminated by court order; (5) the death of the child who is the subject of the affidavit; or (6) the death of the grandparent who executed the affidavit. A parent, guardian, or custodian may negate, reverse, or disapprove a grandparents action or decision only by delivering written notice of negation, reversal, or disapproval to the grandparent and the person acting on the grandparents action or decision in reliance on this affidavit. If this affidavit terminates other than by the death of the grandparent, the grandparent who signed this affidavit shall notify, in writing, all of the following: (a) Any schools, health care providers, or health insurance coverage provider with which the child has been involved through the grandparent; (b) Any other person or entity that has an ongoing relationship with the child or grandparent such that the person or entity would reasonably rely on the affidavit unless notified of the termination; (c) The court in which the affidavit was filed after its creation. The grandparent shall make the notifications not later than one week after the date the affidavit terminates. The decision of a grandparent to consent to or to refuse medical treatment or school enrollment for a child is 7. superseded by a contrary decision of a parent, custodi an, or guardian of the child, unless the decision of the parent, guardian, or custodian would jeopardize the life, health, or safety of the child. Additional information: To caretakers: If the child stops living with you, you are required to notify, in writing, any school, health care provider, or health care insurance provider to which you have given this affidavit. You are also required to notify, in 1. 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 affidavit unless notified. Th