Fill and Sign the Louisiana Statutory Form

PROVISIONAL CUSTODY BY MANDATE (Louisiana Revised Statutes 9:954) STATE OF LOUISIANA PARISH OF _____________________ BE IT KNOWN THAT on this _______ day of ___________________________ , 20 ____ , before me, the undersigned notary, and in the presence of the competent witnesses hereinafter named and undersigned: Personally came and appeared: _________________________________ _________________________________ (affiant's name, marital status, and mailing address), who is the (person(s) having parental authority) of _________________________________ (child(ren)) and who, by these presents makes, names, constitutes, and appoints _________________________________ (mandatary's name and mailing address) and grants provisional custody of each of the above named children, to provide for the health, education, and welfare of each child as provided by the law on Provisional Custody by Mandate, specifically including the authority to: INITIAL ALL APPLICABLE PROVISIONS: _____ (1) Consent to and authorize such medical care, treatment, or surgery as may be necessary for the health, safety, and welfare of each child. _____ (2) Enroll each child in such schools or educational institutions as may be necessary for his proper education. _____ (3) Discipline each child in such reasonable manner as may be necessary for his proper rearing, supervision, and training. _____ (4) Do and perform all other such acts as may be necessary for the shelter, support, and general welfare of each child. This Provisional Custody by Mandate will continue to be effective until ________________ , 20 _____ , or one year from date hereof, whichever period is shorter. I agree that any third party who receives a copy of this document may rely upon the authority granted the mandatary as indicated herein and may act in reliance on such authority. I agree to indemnify and hold harmless the third party for any claims that arise against him because of reliance on this Provisional Custody by Mandate. The undersigned mandatary does hereby accept the provisional custody of each child named herein. THUS DONE AND PASSED at _________ , state of ____________________________ , in the presence of the undersigned, competent witnesses, who sign these presents with the appearer(s) and me, notary, after due reading of the whole. Parent, Tutor, Tutrix, or grandparent awarded custody: ________________________________________________________ Other parent, Cotutor, or grandparent awarded custody: Agent: ______________________________________________________________________ WITNESSES: ______________________________________________________________________________ ______________________________________________________________________________ NOTARY PUBLIC: ____________________________________________________________