Fill and Sign the Provisional Custody by Mandate Louisiana Form

STATE OF LOUISIANA PARISH OF [_PARISH_] PROVISIONAL CUSTODY BY MANDATE BE IT KNOWN THAT on [_Date_] , before me, the undersigned notary, and in the presence of the competent witnesses hereinafter named and undersigned: Personally came and appeared: [_FATHER_NAME_] and [_MOTHER_NAME_] , who are the [_Parents_] of [_CHILD_] who, by these presents make, name, constitute and appoint [_AGENT_NAME_] , [_AGENT_ADDRESS_] and grant provisional custody of the above named child, to provide for the health, education and welfare of the 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 deemed necessary for the health, safety, and welfare of the child. ________ (2) Enroll the child in such schools or educational institutions as may be deemed necessary for [_his_her_] due and proper education. ________ (3) Discipline the child in such reasonable manner as may be necessary for [_his_her_] 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 the child. This Provisional Custody by Mandate will be continue to be effective until [_end_date_] , or one year from date hereof, whichever period is shorter. I agree that any party who receives a copy of this document may rely upon the authority granted the agent as indicated herein and may act in reliance on such authority. Revocation or termination by operation of law is not effective as to a third party until he has actual knowledge thereof. 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 agent does hereby accept the provisional custody of the child named herein. THUS DONE AND PASSED at [_City_Parish_] , State of Louisiana, in the presence of [_Witness1_] and [_Witness2_] , competent witnesses, who sign these presents with appearers and me, notary, after due reading of the whole. WITNESSES: _______________________ _____________________________ [_FATHER_NAME_] _______________________ ____________________________ [_MOTHER_NAME_] ___________________________ [_AGENT_NAME_] _____________________________ [_NOTARY_] , NOTARY PUBLIC * * * * * * * * * * PROVISIONAL CUSTODY BY MANDATE - F1DFAM4: This is the statutory form for a mandate granting a person of legal age the authority to provide for the care, custody and control of a minor child. This authority is granted by the parents acting jointly or, in the event of divorce or separation from bed and board, the natural tutor (or cotutors acting jointly). This authority must be express (R.C.C. 2997) and is subject to the limitations set forth in R.S. 9:951-953. The statutory form is set forth in R.S. 9:954. In this example, both parents join in the grant of provisional custody. WORD KEY EXPLANATION [_PARISH_] Parish in which act is executed. [_Date_] Date act is executed. [_FATHER_NAME_] Full name of father appearing to grant custody. In this example, both parents appear. [_MOTHER_NAME_] Full name of mother appearing to grant custody. [_Parents_] Indicate status as parents or parent, or natural tutor or cotutors where parents are divorced or separated. [_CHILD_] Full name of child. [_AGENT_NAME_] Full name of person to whom provisional custody is granted. [_AGENT_ADDRESS_] Mailing address of agent. [_his_her_] His or her, as appropriate for child. [_end_date_] Date provisional custody is to end. May not be more than one year after grant of provisional custody. [_City_Parish_] City and parish of execution. [_NOTARY_] Notary public before whom act is executed. [_Witness1_] Name of first witness. [_Witness2_] Name of second witness.