Fill and Sign the Designated Caregiver Agreement Statutory Form Minnesota

DESIGNATED CAREGIVER AGREEMENT (Minnesota Statutes 257B.01 to 257B.10) EXPLANATION A parent who has legal custody of a child may execute a designated caregiver agreement that names an adult to serve as a designated caregiver to care for the parent's minor child for a period of time specified in the designated caregiver agreement, but not to exceed one year. The agreement must be executed by all parents with legal custody of the child and must have the consent of every parent who has court-ordered visitation rights to the child. The designation must be signed by the designator in the presence of two witnesses who are 18 years of age or older and not otherwise named in the designation. The witnesses must also sign the declaration. If the designator is physically unable to sign the designation, the designator may direct another person not named in the designation to sign on the designator's behalf in the presence of the designator and both witnesses. A parent may appoint an alternate designated caregiver who would serve if the designated caregiver is unwilling or unable to serve. All requirements applying to a designated caregiver also apply to an alternate designated caregiver. A parent may cancel a designated caregiver agreement at any time. The parent shall notify the designated caregiver of the cancellation. If the designated caregiver is caring for the child at the time of cancellation, the child must be returned to the parent immediately upon the parent's request. DESIGNATION OF CAREGIVER I, ______________________________ , do hereby appoint _______________________________________________________ (insert name, address, and telephone number of standby or temporary custodian) as the standby or temporary custodian of ______________________________ (insert name(s) of child(ren)) to take effect upon the occurrence of the following triggering event or events ______________________________ . I am the ______________________________ (insert designator's relationship to child(ren)) of _________________________________________ (insert name(s) of child(ren)). ______________________________ is the other parent of _________________________________________________________ (insert name(s) of child(ren)). The other parent's address is: ____________________________________________ (check all that apply): The other parent died on ______________________________ (insert date of death). The other parent's parental rights were terminated on ______________________________ (insert date of termination). The other parent's whereabouts are unknown. I understand that all living parents whose rights have not been terminated must be given notice of this designation pursuant to the Minnesota Rules of Civil Procedure or a petition to approve this designation may not be granted by the court. The other parent is unwilling and unable to make and carry out day-to-day child-care decisions concerning the child(ren). The other parent consents to this designation and has signed this form below. By this designation I am granting ______________________________ (insert name of standby or temporary custodian) the authority to act for 60 days following the occurrence of the triggering event as a co-custodian with me, or in the event of my death, as custodian of my child(ren). A temporary custodian appointment terminates upon the death of the designator. (Optional) I hereby nominate ______________________________ (insert name, address, and telephone number of alternate standby custodian) as the alternate standby custodian to assume the duties of the standby custodian named above if the standby custodian is unable or unwilling to act as a standby custodian. If I have indicated more than one triggering event, it is my intent that the triggering event which occurs first shall take precedence. If I have indicated "my death" as the triggering event, it is my intent that the person named in the designation to be standby custodian for my child(ren) in the event of my death shall be appointed as guardian of my child(ren) under Minnesota Statutes, sections 524.5-201 to 524.5-317, upon my death. It is my intention to retain full parental rights to the extent consistent with my condition and to retain the authority to revoke the appointment of a standby or temporary custodian if I so choose. This designation is made after careful reflection, while I am of sound mind. ____________________ _________________________________________ (Date) (Designator's Signature) (Witness' Signature) ______________________________ (Number and Street) ______________________________ City, State, and Zip Code) (Witness' Signature) ______________________________ (Number and Street) ______________________________ City, State, and Zip Code) IF APPLICABLE: I, ______________________________ (insert name of other parent) hereby consent to this designation. ______________________________ (Date) _______________________________________ (Signature of other parent)       (Address of other parent) I, ______________________________ , (insert name of standby or temporary custodian), hereby accept my nomination as standby or temporary custodian of (insert child(ren)'s name(s)). I understand that my rights and responsibilities toward the child(ren) named above will become effective upon the occurrence of the above-stated triggering event or events. I further understand that in order to continue caring for the child(ren), I must file a petition with the court within 60 days of the occurrence of the triggering event. ______________________________ (Date) (Signature of Standby or Temporary Custodian)