Grandparent’sPowerof Attorney
InformationandForms
NOTICE AND DISCLAIMER
The forms in this packethavebeen provided toyou as apublicservicebytheButlerCounty JuvenileCourt. Althoughyou mayusethese forms and representyourselfin this case,you are cautioned that ifyouchoose to do so, youareproceeding atyourownrisk.
-TheButlerCountyJuvenileCourt does not and cannot warrant that theenclosed forms will belegallysufficientforuse foryourparticular circumstances.
-You areadvised that thestaffofthis court arenotqualified to provideyouwith legal advice, this court, therefore, does not andcannot warrant thatanyadvice,guidance, or approvals provided bythestaffoftheButlerCountyJuvenileCourt will be accurateor ultimatelyacceptablebythe court.
-Ifyou haveconcerns regardingthese forms,yourlegal rights, oryour responsibilities, you are advised to consult with aqualified attorney.
Pleaseprint theinformationontheform(s). All portions oftheform(s)mustbecomplete. Ifyoudo nothave requestedinformation(suchas a DateofBirthor thenameofa parent) youshould print“Unknown” inthe correctarea ontheform(s). Incomplete, soiled, damaged, orillegibleforms will notbefiled. Forms thatarefilledoutincorrectly will not befiled. Youmustsubmittheoriginal and onecopyperchildwhenfiling.
CAUTION!
Someofthedocumentsinthis packetmustbenotarized. Thatmeans thatyoumuststate thatthey
are trueunderoath. Ifyoumakeamaterial falsestatementona notarized document, this court has a duty to refer thematter to thecriminal divisionoftheofficeoftheprosecuting attorney. If youmakea falsestatementunderoathyoumaybeprosecutedforperjury. Perjury, underOhio Law, is afelony.
NOTICE:This courtmay notify ButlerCounty Children Services concerning any documentwhichyoufile.
DEFINITIONSAND INSTRUCTIONSFOR
THECOMPLETION OF POWER OFATTORNEY FORMS AND ASSOCIATED DOCUMENTS
You must submit the followingchecklist withyour completed documents. YOU CANNOT EXECUTE(SIGN) ORFILE THEPOWER OFATTORNEY(POA)FORMUNLESS ALLOF THESTATEMENTS ON THE CHECKLIST ARE TRUE. You should check offeachitem.Ifany itemisnot true, youcannotfile thePOA.
GrandparentPowerofAttorney (POA)Checklist
ThePOA cannot be filedunless all statements arechecked offas beingtrue(onlyoneofthe statements in section 4 must betrue). Court staffwill go overthis form withyou to verifyits accuracy.
9.ThePOA contains thenameofthe child and the child’s dateofbirth. 10.Thenamed child is undertheageof18.
11.ThePOA pertains to onlyonechild.
12.ThePOA contains complete and legible answers to all questions set forth on the
JuvenileCourt FaceSheet.
13.The form is correctlynotarized (Signedand dated byanOhio notarypublic, sealed and stamped).
14.ThePOA was signedandnotarized within thepast five (5)days.
15.Thereis no othernon-expired POA oron filewith the court regardingthechild. The followingstatementmust betrueonlyifthe conditions as set forth in #4 ForG (above) are
true.
ThePOA has been presented accompanied byareceipt showingthat noticeofthe creation ofthePOA was sent bycertified mail to anyparent required to benotified (See#4 FG above).
DEFINITIONSAND INSTRUCTIONS
CHILD SUPPORT
-Therearenoforms enclosed in this packet which relateto child support. The filingof
thesedocuments does not modifyanyexistingsupport obligation nordoes the filingof either form commence anynew support order regardingthe child.
CLERK'SOFFICE
-The clerk's officeis located on the first flooroftheJuvenileJusticeCenterlocated at 280
North FairAvenue,Hamilton, Ohio 45011.
-Whenyou need to filepapers orneed otherinformation from the clerk's office,you should go to theINFORMATION window on thefirst floor.
COMPLETION OF FORMS
-Youshould use thePowerofAttorney (POA)formifoneorbothofthechild’s parents will signtheform. Both parents shouldsignthePOA formunless the signingparent canverify that theinformationintheaffidavit regarding thelackof theotherparent’s signatureis true.
-YoushouldreadthePOA formandcarefully beforeyousign. TheformCANNOT
bealteredandMUST be completely trueandaccurateto bevalid.
-You should type (ifpossible)orlegiblyprint (in black ink) all ofyourresponses.
-You should complete all documents priorto filing them.
-You must have all documents which contain asignatureline foranotarypublicnotarized byanOhio NotaryPublic*.
-You must provideCOMPLETE information includingthenames and complete addresses foryourselfand forall persons required in the forms includingthe city, state, andZip Codeoftheir residence.
-Onceyougiveyourdocuments to the clerk, thedocuments will be reviewed for approval.
You will benotified regardingwhetherornotyourdocuments havebeen filed.
-Once approvedyourdocuments will be filed,youmaypick upa file-stamped copyof yourform at the court.
-Thestaffwho reviewyourdocuments arenotattorneys. They cannotgiveyoulegaladvice. Theirapproval ofyourdocuments for filing shouldin nowaybe construedas approval ofyourformby thecourtoras a guaranteeofyourform’svalidity.
-Incomplete, damaged, soiled, orillegibleforms willnotbeaccepted.
*Notaryservices arenotprovided bythis court. Notaryservices areprovided bymanybanks and savings and loan companies, byall attorneys, and bysomebusinesses(in theYellow Pages underNOTARIES-PUBLIC).
COPIESOFDOCUMENTS
-It is agood ideato makecopies of everydocument thatyou filewith the court foryour records. Whensubmittingdocuments to file, youmusthave theoriginal and onecopy for eachchild.
COSTS
-Thereis no filingfee forthe filingofeitheraPOAoraCAA. Ifyouwish to havea
certifiedcopyofyourPOA orCAA, therewill beasmall feeassessed bythe clerk’s office.
CUSTODY
-These forms when filedgivetheholderthe authorityto enroll thenamed child in school
and to consent to medicaltreatment forthechild. The forms do notgivetheholderthe authorityto denyeitherparent custody, visitation, or contact with the child. The forms do not necessarilyentitletheholderto obtain amedical card ormedical insuranceforthe child. The forms do notnecessarilyentitletheholderto the receipt of childsupport for the child.
OTHER REQUIRED DOCUMENTS
-Ifyou cannot obtain thesignatures ofboth parents on thePOA andyou know the
whereabouts oftheparent who did not sign,youmust notifythat parent(ifthat person is thelegal parent) (SeeAppendixF)thatyou haveexecuted thePOA unless thereis a protection orderissued which prohibits theotherparent from beingso notified orunless theotherparent’s parental rights havebeen terminated bycourt order. In providingthat notice,you must providethat parent with thenotice form in this packet togetherwith a copyofthePOA andyoumust send thosedocuments to theotherparent bycertified mail. You must attach copies ofthat notice along withyourcertified mailreceipt to the POA form whichyou present to the court for filing.
-You must completelyfillout thePowerofAttorneyand JuvenileCourt FaceSheet. This document MUST besubmitted to the court with thePOA. The court CANNOT fileyour POA without the facesheet.
ENCLOSED DOCUMENTSIN THISPACKETINCLUDE: FaceSheet
AppendixB: POA form
JUVENILE COURT
JuvenileCourtFaceSheet
CHILD INFORMATION:
Name
LastFirstMiddle
Childalso known as
LastFirstMiddle
SSN: DOB:
Gender: Race:
(Optional)
(Optional)
Birth City/State:
BeforeRemovalofChild(ifapplicable):
Address
Number/StreetCity/StateZip
Schooland Grade:
SchoolDistrict:
BIOLOGICALPARENTINFORMATION:
Mother’sName
LastFirstMiddle
Also known as
LastFirstMiddle
Address:
Number/StreetCity/StateZip
PhoneNumber:
SSN:
(Optional)
DOB:
Gender:
Race:
CustodyType:
MaritalStatus:
(optional)(legal, temporary)
InterpreterNeeded:_NA_ Language NA
(married, divorced,never married,etc...)(yesor no)
ForWhom:NA
Advertisementneeded _NA
Father’sName
LastFirstMiddle
Also known as
LastFirstMiddle
Address:
Number/StreetCity/StateZip
PhoneNumber:
SSN:
(Optional)
DOB:
Gender:
Race:
CustodyType:
MaritalStatus:
(Optional)(legal,temporary)
InterpreterNeeded:_NA_ Language NA
(married, divorced,never married,etc...)(yesor no)
ForWhom:NA
Advertisementneeded _NA
Name
LastFirstMiddle
Also known as
LastFirstMiddle
Address:
Number/StreetCity/StateZip
PhoneNumber:
SSN:
DOB:
Gender:
Race:
CustodyType:
(legal, temporary)
MaritalStatus:
InterpreterNeeded:_NA_ Language NA
(married, divorced,never married,etc...)(yesor no)
ForWhom:NA
Advertisementneeded _NA
Name
LastFirstMiddle
Also known as
LastFirstMiddle
Address:
Number/StreetCity/StateZip
PhoneNumber:
SSN:
DOB:
Gender:
Race:
CustodyType:
(legal, temporary)
MaritalStatus:
InterpreterNeeded:_NA_ Language NA
(married, divorced,never married,etc...)(yesor no)
ForWhom:NA
Advertisementneeded _NA
GRANDPARENTNAMEDIN THEPOWER OFATTORNEY:
Name:
LastFirstMiddle
Also known as
LastFirstMiddle
Address:
Number/StreetCity/StateZip
PhoneNumber:
SSN:
DOB:
Gender:
Race:
CustodyType:
MaritalStatus:
(Optional)(legal,temporary)
InterpreterNeeded:_NA_ Language NA
(married, divorced,never married,etc...)(yesor no)
ForWhom:NA
Advertisementneeded _NA
Appendix A
POWEROFATTORNEY
I (We),(parent(s)) the undersigned, residing at
(address), in the countyof , stateof
, herebyappoint thechild'sgrandparent, residing at
(grandparent’s address)in the countyof , in thestateofOhio, with whom the child ofwhomIam theparent,guardian, or custodian is residing, myattorneyin fact to exercise anyand all ofmyrights and responsibilities regardingthe care, physical custody, and control ofthe child, born havingsocial securitynumber (optional), except myauthorityto consent to marriageor adoption ofthe child and to perform all acts necessaryin the execution of the rights andresponsibilities hereby granted, as fullyasImight do ifpersonallypresent. The rightsIam transferringunderthis powerofattorneyincludethe abilitytoenroll the child in school, to obtain from theschool district educational and behavioral information about the child, to consent to all school-related matters regardingthe child, and to consent to medical, psychological, ordental treatment forthe child. This transferdoes not affect myrights in any futureproceedings concerningthecustodyofthechild orthe allocation oftheparental rights and responsibilities forthe careofthechild and does not givetheattorneyin fact legal custodyofthe child. This transferdoes not terminatemyright tohave regular contact with the child.
IherebycertifythatIamtransferringthe rights and responsibilities designated in this powerof attorneybecauseoneofthe following circumstances exists:
(1)Iam: (a)Seriouslyill, incarcerated or about tobeincarcerated, (b)Temporarilyunableto provide financial support orparental guidanceto the child, (c)Temporarilyunableto provide adequatecare and supervision ofthe child becauseofmyphysical ormental condition, (d) Homeless orwithout a residencebecausethe current residenceis destroyedorotherwise uninhabitable, or (e)In or about to entera residential treatment program forsubstance abuse;
(2)Iam aparent ofthechild, the child's otherparent is deceased, andIhave authoritytoexecute thepowerofattorney; or
This Spaceis forCourtUseOnly
(3)Ihaveawell-foundedbeliefthat thepowerofattorneyis in the child'sbest interest.
IherebycertifythatIamnot transferringmyrights and responsibilities regardingthe child forthe purposeof enrollingthechild in aschool orschool district so that the child mayparticipatein the academicorinterscholastic athleticprograms provided bythat school ordistrict.
Iunderstand that this document does not authorizea child support enforcement agencyto redirect child support payments to thegrandparent designated as attorneyin fact.I furtherunderstand that to have an existingchildsupport ordermodified oranewchild support orderissued administrativeorjudicial proceedings must beinitiated.
Ifthereisa court ordernamingmetheresidentialparent and legal custodian ofthe child who is thesubject ofthis powerof attorneyandIam thesoleparent signingthis document,Ihereby certifythat oneofthe followingis the case:
(1)Ihavemadereasonable efforts to locate and providenoticeofthecreation ofthis powerof attorneyto theotherparent and havebeen unableto locatethat parent;
(2)Theotherparent is prohibited from receiving anoticeof relocation; or
(3)Theparental rights oftheotherparent havebeen terminated byorderofajuvenile court.
This POWEROFATTORNEY is valid until theoccurrenceofwhicheverofthe following events occurs first: (1)Irevokethis POWEROFATTORNEY in writing; andgivenoticeofthe revocation to thegrandparent designatedas attorneyin fact and thejuvenilecourt with which this POWEROFATTORNEY was filed; (2)the childceases to residewith thegrandparent designated as attorneyin fact; (3)this POWEROFATTORNEY is terminated bycourt order; (4) thedeath ofthechild who is thesubject ofthepowerofattorney; or (5)thedeath ofthe grandparent designatedas the attorneyin fact.
WARNING: DO NOT EXECUTE THIS POWEROFATTORNEYIFANY STATEMENT MADEIN THISINSTRUMENTISUNTRUE.FALSIFICATIONISA CRIME UNDER SECTION 2921.13OFTHE REVISED CODE, PUNISHABLE BY THESANCTIONSUNDER CHAPTER2929. OFTHE REVISED CODE,INCLUDING A TERM OFIMPRISONMENT OF UPTO 6 MONTHS, A FINE OFUPTO $1,000,ORBOTH.
Witness myhand this dayof ,
Parent/Custodian/Guardian's signature
Parent's signature
Grandparent designatedas attorneyin fact
StateofOhio ))ss:
Countyof )
Subscribed, sworn to, and acknowledged beforemethis dayof ,
NotaryPublic
Notices:
1.A powerofattorneymaybe executed onlyifoneofthe following circumstances exists: (1)Theparent,guardian,or custodian ofthe childis: (a)Seriouslyill, incarcerated or about to beincarcerated;(b)Temporarilyunableto provide financial support orparental guidanceto the child; (c)Temporarilyunableto provide adequatecareandsupervision of the child becauseoftheparent's,guardian's, or custodian's physical ormental condition; (d)Homeless orwithout a residencebecausethecurrent residenceis destroyed or otherwiseuninhabitable;or (e)In or about to entera residential treatment program for substance abuse; (2)Oneofthe child's parents is deceased and theotherparent, with authorityto do so, seeks to executeapowerof attorney; or (3)Theparent,guardian, or custodian has awell-founded beliefthat thepowerof attorneyis in the child's best interest.
2.Thesignatures oftheparent, guardian, orcustodian ofthe child and thegrandparent designated as theattorneyin fact must benotarized byanOhio notarypublic.
3.A parent,guardian, orcustodian who creates apowerofattorneymust notifytheparent
ofthe child who is not the residential parent and legal custodian ofthechild unless oneof the followingcircumstances applies: (a)theparentis prohibited from receivinganotice
of relocation in accordancewith section 3109.051oftheRevised Codeofthe creation of thepowerofattorney; (b)theparent's parental rights havebeen terminated byorderofa
juvenile court pursuant to Chapter2151. oftheRevised Code; (c)theparent cannot be located with reasonable efforts; (d)both parents are executingthepowerofattorney. The noticemust besent bycertified mail not laterthanfivedays afterthepowerof attorneyis created and must statethename andaddress oftheperson designated as the attorneyin fact.
4.A parent,guardian, orcustodian who creates apowerofattorneymust fileit with the juvenile court ofthecountyin which theattorneyin fact resides, or anyother court that has jurisdiction overthechild underapreviouslyfiled motion orproceeding. Thepower of attorneymust be filednot laterthan fivedaysafterthedateit is createdand be accompanied byareceiptshowingthat thenoticeof creation ofthepowerof attorney was sent to theparent who is not the residential parent and legalcustodian bycertified mail.
5.This powerof attorneydoes not affect the rights ofthe child's parents,guardian, or custodian regarding anyfutureproceedings concerningthe custodyofthechild orthe allocation oftheparentalrights andresponsibilities forthe careofthe childand does not givetheattorneyin fact legal custodyofthechild.
6.A person orentitythat relies on this powerof attorney, in good faith, has no obligation to make anyfurtherinquiryorinvestigation.
7.This powerof attorneyterminates on theoccurrenceofwhicheverofthefollowing occurs first: (1)thepowerof attorneyis revoked in writingbythepersonwho created it and that persongives written noticeoftherevocation to thegrandparent who is the attorneyin fact and thejuvenile court with whichthepowerofattorneywas filed; (2)the child ceases to livewith thegrandparent who is the attorneyin fact; (3)thepowerof attorneyis terminated bycourt order;(4)thedeathofthe child who is thesubject ofthe powerofattorney; or (5)thedeath ofthegrandparent designated as theattorneyin fact.
Ifthis powerofattorneyterminates otherthan bythedeath oftheattorneyin fact, the grandparent who servedas the attorneyin fact shall notify, in writing,all ofthe following:
(a)Anyschools, health careproviders, orhealth insurancecoverageproviderwith which the child has been involved through thegrandparent;
(b)Anyotherperson or entitythat hasan ongoing relationship with the child or grandparent such that theotherperson orentitywould reasonablyrelyon thepower of attorneyunless notified ofthetermination;
(c)The court in which thepowerofattorneywas filed afterits creation;
(d)Theparent who is not the residential parent and legalcustodian ofthe childwho is required to begiven noticeofits creation. Thegrandparent shall makethe notifications not laterthan oneweekafterthedatethepowerofattorneyterminates.
8.Ifthis powerofattorneyis terminated bywritten revocation ofthepersonwho created it, orthe revocation is regardingasecond orsubsequent powerofattorney, a copyofthe revocation must be filedwith the court with which that powerofattorneywas filed.
Additional information:
To thegrandparentdesignatedas attorney infact:
1.Ifthe child stops living withyou,you arerequired to notify, in writing,anyschool, health careprovider, orhealth careinsuranceprovidertowhichyou havegiven this powerof attorney. You are also required to notify, in writing, anyotherperson or entitythat has an ongoingrelationship withyou orthe child such that theperson orentitywould reasonably relyon thepowerof attorneyunless notified. Thenotification must bemadenot laterthan oneweekafterthe childstops livingwithyou.
2.You must includewith thepowerof attorneythefollowinginformation:
a.The child's presentaddress, the addresses oftheplaces wherethe child haslived within thelast fiveyears,and thenameand present address ofeach personwith whom the child has lived duringthat period;
b.Whetheryou haveparticipated as aparty, awitness, orin anyothercapacityin anyotherlitigation, in this stateor anyotherstate,that concerned the allocation, between theparents ofthesame child, ofparentalrights andresponsibilities for the careofthechild and thedesignation oftheresidential parent and legal custodian ofthe child orthat otherwise concernedthe custodyofthesamechild;
c.Whetheryou haveinformation of anyparenting proceeding concerningthe child pendingin acourt ofthisor anyotherstate;
d.Whetheryou know of anyperson who has physical custodyofthe child orclaims to beaparent ofthe childwho is designated the residential parent and legal custodian ofthe child orto haveparentingtime rights with respect to thechild or to beaperson otherthanaparent ofthe child whohas custodyorvisitation rights with respect to the child;
e.Whetheryou previouslyhavebeen convicted oforpleadedguiltyto anycriminal offenseinvolvinganyactthat resulted in a child being an abusedchild ora neglectedchild orpreviouslyhavebeen determined, in a casein whicha child has been adjudicated an abused child oraneglectedchild, to betheperpetratorofthe abusiveorneglectful actthat was thebasis oftheadjudication.
3.Ifyou receivewritten noticeofrevocation ofthepowerof attorneyortheparent, custodian, orguardianremoves the child fromyourhome and ifyou believethat the revocation orremoval isnot in thebest interest ofthe child,you may,within fourteen days,filea complaint in thejuvenile court to seekcustody. You mayretainphysical custodyofthe child until the fourteen-dayperiodelapses or, ifyoufileacomplaint, until the court orders otherwise.
School Officials:
1.Except as provided in section 3313.649 oftheRevised Code, this powerofattorney, properlycompletedandnotarized, authorizes the child in question to attend school in the district in which thegrandparent designated as attorneyin fact resides andthat grandparent is authorized to provide consent in allschool-related matters and to obtain from theschool district educational and behavioral information about thechild. This powerofattorneydoes not precludetheparent,guardian, orcustodian ofthe child from having access to all school records pertinent to the child.
2.Theschool district mayrequire additional reasonable evidencethat thegrandparent lives in theschool district.
3.A school district orschool official that reasonablyand ingoodfaith relieson this power of attorneyhas no obligation to make anyfurtherinquiryorinvestigation.
To healthcareproviders:
1.A person orentitythat acts in good faith relianceon apowerof attorneytoprovide medical, psychological, ordental treatment, without actual knowledgeof facts contraryto thosestated in thepowerof attorney, is not subjectto criminal liabilityortocivil liability to anyperson orentity, and is not subject to professional disciplinaryaction, solelyfor such relianceifthepowerof attorneyis completed and thesignatures oftheparent, guardian, orcustodian ofthe child and thegrandparent designated as attorneyin fact are notarized.
2.Thedecision ofagrandparent designated as attorneyin fact, based on apowerof attorney, shall behonored byahealth carefacilityorpractitioner, school district, or school official.
Appendix C
RevocationofPowerofAttorney
I(We), theundersigned, residingat , in the countyof , stateof , theparent(s)ofthe child born on havingpreviouslyappointed said child'sgrandparent, , residing at
, in the countyof , in the stateofOhio, myattorneyin fact to exercise anyand all ofmyrights andresponsibilities
regardingthecare, physical custody, and control ofsaid child, herebyrevokes that appointment.
Bysignature(s)below theparent(s)certifythat acopyofthis revocation has been filedwith the court wheretheoriginalpowerofattorneywas originallyfiled and thatacopyofthis revocation
has been served upon thegrandparent named in said powerof attorney.
SignatureofParent whoexecutedDate
Original PowerofAttorney
SignatureofParent whoexecutedDate