Fill and Sign the Mississippi General Form

POWER OF ATTORNEY: CARE AND CUSTODY OF CHILD OR CHILDREN 1. I certify that I am the parent or legal custodian of: _______________________________ (Full name of minor child) (Date of birth) _______________________________ (Full name of minor child) (Date of birth) _______________________________ (Full name of minor child) (Date of birth) who is/are minor children. 2. I designate _______________________________ (Full name of attorney-in-fact) ________________________________________________________ (Street address, city, state and zip code of attorney-in-fact) ________________________________________________________ (Home phone, work phone and cell phone of attorney-in-fact) as the attorney-in-fact of each minor child named above. 3. [Complete either Section 3(a) or 3(b)]. (a) I delegate to the attorney-in-fact all of my power and authority regarding the care, custody and property of each minor child named above, including, but not limited to, the right to enroll the child in school, inspect and obtain copies of education records and other records concerning the child, the right to attend school activities and other functions concerning the child, and the right to give or withhold any consent or waiver with respect to school activities, medical and dental treatment, and any other activity, function or treatment that may concern the child. This delegation shall not include the power or authority to consent to marriage or adoption of the child, the performance or inducement of an abortion on or for the child, or the termination of parental rights to the child. OR (b) I delegate to the attorney-in-fact the following specific powers and responsibilities (write in): ________________________________________________________ ________________________________________________________ [If Section 3(b) is completed, Section 3(a) does not apply.] This delegation shall not include the power or authority to consent to: marriage or adoption of the child, performing or inducing an abortion on or for the child, or the termination of parental rights to the child. [Complete either 4(a) or 4(b)] 4. (a) This power of attorney is effective for a period not to exceed one (1) year, beginning, ________________________ , 20 _________ , and ending , 20 . I reserve the right to revoke this authority at any time. OR [Complete either 4(a) or 4(b)] (b) I am a serving parent as defined in Section 93-31-3, Mississippi Code of 1972. My active- duty service is scheduled to begin on _______________________________ , 20 _________ , and is estimated to end on ______________ , 20 _________ . I reserve the right to revoke this authority at any time. I acknowledge that in no event may this delegation of power last more than one (1) year or the term of my active duty plus thirty (30) days, whichever is longer. By: ____________________________________________________ (Parent/Legal Custodian signature) 5. I hereby accept my designation as attorney-in-fact for the minor child/children specified in this power of attorney. ___________________________________________________ (Attorney-in-fact signature) State of ______________ County of ______________ ACKNOWLEDGEMENT Before me, the undersigned, a Notary Public, in and for said county and state on this day of ______________ , 20 _________ , personally appeared (Name of Parent/Legal Custodian) and (Name of attorney-in-fact), known to me to be the persons who executed this instrument and who acknowledged to me that each executed the same as his or her free and voluntary act and deed for the uses and purposes set forth in the instrument. Witness my hand and official seal the day and year above written. ________________________________________________ (Signature of notarial officer) (Seal, if any) (Title and Rank) My commission expires: ______________