Fill and Sign the General Power of Attorney for Care and Custody of Child or Children Minnesota Form

DELEGATION OF POWERS BY PARENT M INN . S TAT . § 524.5-211 STATE OF MINNESOTA ) ) ss. COUNTY OF _____________ ) KNOW ALL PERSONS BY THESE PRESENTS THAT: 1 I, ____________________________ , of the County of ____________________________ , State of Minnesota, am the parent of ____________________________ , born ____________________________ , _____________ . 2 I hereby appoint ____________________________ , of the County of ____________________________ , State of Minnesota, to be my true and lawful Attorney in Fact for the exercise of parental authority over my child, ____________________________ , for a period of ____________________________ (up to one year) following the date of my signature, pursuant to M INN . S TAT . § 524.5-211. 3 This Power of Attorney hereby constitutes my delegation to ____________________________ , of my parental powers and authority regarding the care, custody, and property of ____________________________ , including, but not limited to the authority to: a. authorize medical treatment; b.. enroll my child in school; and c. provide a home, care, and supervision of my child at the home of ____________________________ . This Power of Attorney does not authorize ____________________________ to consent to marriage or adoption of ____________________________ . I, ____________________________ , understand that I am legally obligated, pursuant to M INN . S TAT .§ 524.5-211(b) to mail or give a copy of this document to any other parent within 30 days of its execution unless: a. the other parent does not have visitation rights or has supervised visitation rights; or b. there is an existing order for protection under chapter 518B or similar law of another state in effect against the other parent to protect me. IN TESTIMONY WHEREOF, I have hereunto set my hand this _____ day of ____________________________ , 20 _____ . ____________________________________ Signature of Parent or Guardian STATE OF MINNESOTA ) ) ss. COUNTY OF ) The foregoing instrument was acknowledged before me this ___. day of .__________, _______ by __________________________ (Insert Name of Principal) ____________________________________________ (Signature of Notary Public or other Official) Acknowledgement of notice to attorney(s)-in-fact and specimen signature of attorney(s)-in-fact. By signing below, I acknowledge I have read and understand the IMPORTANT NOTICE TO ATTORNEY(S)-IN-FACT required by Minnesota Statutes, section 523.23, and understand and accept the scope of any limitations to the powers and duties delegated to me by this instrument. (Notarization not required) _____________________________________________ This instrument was drafted by: Specimen Signature of Attorney(s)-in-Fact __________________________ (Notarization not required) IMPORTANT NOTICE TO THE ATTORNEY(S)-IN-FACT You have been nominated by the principal to act as an attorney-in-fact. You are under no duty to exercise the authority granted by the power of attorney. However, when you do exercise any power conferred by the power of attorney, you must: (1) act with the interests of the principal utmost in mind; (2) exercise the power in the same manner as an ordinarily prudent person of discretion and intelligence would exercise in the management of the person's own affairs; (3) render accountings as directed by the principal or whenever you reimburse yourself for expenditures made on behalf of the principal; (4) act in good faith for the best interest of the principal, using due care, competence, and diligence; (5) cease acting on behalf of the principal if you learn of any event that terminates this power of attorney or terminates your authority under this power of attorney, such as revocation by the principal of the power of attorney, the death of the principal, or the commencement of proceedings for dissolution, separation, or annulment of your marriage to the principal; (6) disclose your identity as an attorney-in-fact whenever you act for the principal by signing in substantially the following manner: Signature by a person as "attorney-in-fact for (name of the principal)" or "(name of the principal) by (name of the attorney-in-fact) the principal's attorney-in-fact"; (7) acknowledge you have read and understood this IMPORTANT NOTICE TO THE ATTORNEY(S)-IN-FACT by signing the power of attorney form. You are personally liable to any person, including the principal, who is injured by an action taken by you in bad faith under the power of attorney or by your failure to account when the duty to account has arisen. The meaning of the powers granted to you is contained in Minnesota Statutes, chapter 523. If there is anything about this document or your duties that you do not understand, you should seek legal advice.