Fill and Sign the General Power of Attorney for Care and Custody of Child Children or Protected Person Utah Form

Power of Attorney over Protected Person or Minor Child I swear that the following is true : (1) I am the parent court-appointed guardian of _________________________________________ (name) , who was born on _________________________________________ (date) . (2) I appoint the following person as my attorney-in-fact for the person named in Paragraph (1). Name _________________________________________ Address _________________________________________ City, State, Zip _________________________________________ Phone _________________________________________ E-mail _________________________________________ (Check (3) OR (4), not both. If you check (4), describe the authority being delegated.) (3) I delegate to my attorney-in-fact all power and authority that I have as a parent or guardian, except the power to consent to marriage or adoption. (4) I delegate to my attorney-in-fact only the specific authority to: _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ (5) This power of attorney lasts until _______________________________ (date) . (This date must be within the next 6 months.) (6) This power of attorney lasts even in the event of my disability. Power of Attorney over Protected Person or Minor Child Approved Board of District Court Judges January 16, 2009 Revised May 9, 2017 Page 1 of 2 Date Sign here ► Typed or printed name ___________________________ Address ___________________________ City, State, Zip ___________________________ Phone ___________________________ E-mail ___________________________ On this date, I certify that ___________________________ (name) who is known to me or who presented satisfactory identification, in the form of ______________________________________________________ (form of identification) , has, while in my presence and while under oath or affirmation, voluntarily signed this document and declared that it is true. Date: Sign here ► Typed or printed name Notary Seal Power of Attorney over Protected Person or Minor Child Approved Board of District Court Judges January 16, 2009 Revised May 9, 2017 Page 2 of 2