Fill and Sign the Pa Custody Form

NOTICE THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE THE PERSON YOU DESIGNATE (YOUR "AGENT") BROAD POWERS TO HANDLE YOUR PROPERTY, WHICH MAY INCLUDE POWERS TO SELL OR OTHERWISE DISPOSE OF ANY REAL OR PERSONAL PROPERTY WITHOUT ADVANCE NOTICE TO YOU OR APPROVAL BY YOU. THIS POWER OF ATTORNEY DOES NOT IMPOSE A DUTY ON YOUR AGENT TO EXERCISE GRANTED POWERS, BUT, WHEN POWERS ARE EXERCISED, YOUR AGENT MUST USE DUE CARE TO ACT FOR YOUR BENEFIT AND IN ACCORDANCE WITH THIS POWER OF ATTORNEY. YOUR AGENT MAY EXERCISE THE POWERS GIVEN HERE THROUGHOUT YOUR LIFETIME, EVEN AFTER YOU BECOME INCAPACITATED, UNLESS YOU EXPRESSLY LIMIT THE DURATION OF THESE POWERS OR YOU REVOKE THESE POWERS OR A COURT ACTING ON YOUR BEHALF TERMINATES YOUR AGENT'S AUTHORITY. YOUR AGENT MUST ACT IN ACCORDANCE WITH YOUR REASONABLE EXPECTATIONS TO THE EXTENT ACTUALLY KNOWN BY YOUR AGENT AND, OTHERWISE, IN YOUR BEST INTEREST, ACT IN GOOD FAITH AND ACT ONLY WITHIN THE SCOPE OF AUTHORITY GRANTED BY YOU IN THE POWER OF ATTORNEY. THE LAW PERMITS YOU, IF YOU CHOOSE, TO GRANT BROAD AUTHORITY TO AN AGENT UNDER POWER OF ATTORNEY, INCLUDING THE ABILITY TO GIVE AWAY ALL OF YOUR PROPERTY WHILE YOU ARE ALIVE OR TO SUBSTANTIALLY CHANGE HOW YOUR PROPERTY IS DISTRIBUTED AT YOUR DEATH. BEFORE SIGNING THIS DOCUMENT, YOU SHOULD SEEK THE ADVICE OF AN ATTORNEY AT LAW TO MAKE SURE YOU UNDERSTAND IT. A COURT CAN TAKE AWAY THE POWERS OF YOUR AGENT IF IT FINDS YOUR AGENT IS NOT ACTING PROPERLY. THE POWERS AND DUTIES OF AN AGENT UNDER A POWER OF ATTORNEY ARE EXPLAINED MORE FULLY IN 20 PA.C.S. CH. 56. IF THERE IS ANYTHING ABOUT THIS FORM THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER OF YOUR OWN CHOOSING TO EXPLAIN IT TO YOU. I HAVE READ OR HAD EXPLAINED TO ME THIS NOTICE AND I UNDERSTAND ITS CONTENTS. Date: ____________________________ ____________________________ Principal ____________________________ Print Name AGENT’S ACKNOWLEDGMENT I, ____________________________ , have read the attached power of attorney and am the person identified as the agent for the principal. I hereby acknowledge that when I act as agent: I shall act in accordance with the principal's reasonable expectations to the extent actually known by me and, otherwise, in the principal's best interest, act in good faith and act only within the scope of authority granted to me by the principal in the power of attorney. Date: ____________________________ ____________________________ Agent ____________________________ Print Name POWER OF ATTORNEY: CARE AND CUSTODY OF CHILD OR CHILDREN KNOW ALL MEN BY THESE PRESENTS: That the undersigned, __________________________________________ , parent(s) of the child(ren) identified below, residing at _____________________________________________ hereby make, constitute and appoint ____________________________ (if more than one attorney-in-fact is appointed, add 'Jointly," "either of them" or "any one of them" to indicate how they must act) as the true and lawful Attorney(s)-in-Fact of the undersigned, to act in name, place and stead of the undersigned, to do and execute all or any of the following acts, deeds and things with respect to the care and custody of the following child(ren): ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ (a) To participate in decisions regarding the child(ren)’s education including attending conferences with the child(ren)’s teachers or any other educational authorities, granting permission for the child(ren)’s participation in school trips and other activities, and making any other decisions and executing any documents pertinent to their education. (b) To grant permission and consent to the child(ren) participating in any activity sponsored by any group, association or organization which activity the Attorney(s)-in-Fact may deem appropriate. (c) To make health care decisions on behalf of the child(ren), including making decisions regarding the child(ren)’s medical or dental care, whether routine or emergency in nature, including admissions to hospitals or other institutions; to consent to, to refuse to consent to, or to withdraw consent to the provision of any care, tests, treatment, surgery, service or procedure to maintain, diagnose or treat a physical or mental condition, as well as the right to sign such medical forms as may be necessary to carry out such decisions; to talk with health care personnel who may be treating the child(ren) and to examine the child(ren)’s medical records and to consent to the disclosure of such records in circumstances the Attorney(s)-in- Fact may deem appropriate; to file claims for medical insurance and to obtain information from any insurance company with respect to any policy of health or medical insurance under which the child(ren) may be insured; provided however, that the Attorney(s)-in-Fact shall not be required to execute any documents which would involve incurring any personal liability for any such treatment and care, and the undersigned affirms that the undersigned will be responsible for payment for any such care or treatment consented to by the Attorney(s)-in-Fact of the undersigned which is not covered by insurance. (d) To generally do and perform all matters and things, to execute all other instruments of every kind which may be necessary or proper to effectuate all powers hereinabove specifically granted, or any other matter or thing appertaining to the child(ren) of the undersigned, with the same full powers, and to all intents and purposes, with the same validity as the undersigned could, if personally present; and hereby ratifying and confirming whatsoever said Attorney(s)-in-Fact of the undersigned shall and may do, by virtue hereto. (e) SPECIFICALLY EXCLUDED FROM THE AUTHORITY AND POWERS GRANTED HEREIN IS THE AUTHORITY OR POWER TO CONSENT TO THE MARRIAGE OR ADOPTION OF THE CHILD(REN) NAMED HEREIN. The powers herein granted to said Attorney(s)-in-Fact of the undersigned shall be exercisable by any one of them or all of them at any time and from time to time from ____________________ until _______________________ . This Power of Attorney shall remain in full force and effect until the date stated above, and any party dealing with the Attorney (s)-in-fact during such time shall be fully protected and is hereby discharged, released and indemnified from so doing in respect of any matter relating hereto unless such particular party shall have received prior notice in writing of the revocation of this Power of Attorney. We further understand that this temporary power of attorney (delegation) of our parental powers does not relieve us of the primary responsibility of our child. Signed this _________ day of __________________________________ , 20 _________ ______________________________________________ Signature ____________________________ City, County, and State of Residence ATTESTATION OF WITNESSES The hereinafter named Witnesses, each declare under penalty of perjury under the laws of the State of Pennsylvania, that the principal is personally known to us, that the principal signed and acknowledged this special power of attorney in our presence, that the principal appears to be of sound mind and under no duress, fraud or undue influence, that we are not the person appointed as attorney-in-fact by this document and that we witnessed this power of attorney in the presence of the principal. We are 18 years of age or older and not the individuals who signed the power of attorney on behalf of and at the direction of the principal, or the notary public, or other person authorized by law to take acknowledgments before whom the power of attorney is acknowledged We are not related to the principal by blood, marriage or adoption, and to the best of our knowledge, are not entitled to any part of the estate of the principal upon the death of the principal under a will now existing or by operation of law. ____________________________ Signature ____________________________ Printed Name ____________________________ Address ____________________________ Signature ____________________________ Printed Name ____________________________ Address STATE OF PENNSYLVANIA County of ____________________ On this, the ____ day of __________________________________ , 20 ____ , before me __________________________________ , the undersigned officer, personally appeared __________________________________ , known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that he/she executed the same for the purposes therein contained. In witness whereof, I hereunto set my hand and official seal. Signature: _____________________________________________________________________ Title of Officer: _______________________________