403.353 Form of power of attorney authorized by KRS 403.352. (1) A power of attorney established pursuant to this section and KRS 403.352 shall be substantially in the following form, and may include other specific directions which are in accordance with accepted legal practice and not specifically prohibited by any other statute. If any other specific directions are held by a court of appropriate jurisdiction to be invalid, that invalidity shall not affect the power of attorney or other provisions established in this section and KRS 403.352. "Power of Attorney for Temporary Delegation of Parental or Legal Custody and Care 1. I certify that I am the parent or legal guardian of: __________________________________________ (Full name of minor child) __________________________________________ (Full name of minor child) __________________________________________ (Full name of minor child) _______________ (Date of birth) _______________ (Date of birth) _______________ (Date of birth) 2. I designate __________________________ (Full name of Attorney-in-fact), _______________________________________________________________________ (Street address, city, state, and zip code of Attorney-in-fact) _______________________________________________________________________ (Home phone of Attorney-in-fact)____________________________________________ (Work phone of Attorney-in-fact)____________________________________________ 3. 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 In the event that Section 4 is completed, Section 3 does not apply. I delegate to the Attorney-in-fact the following specific powers and responsibilities 4. (write in): ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 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. This power of attorney is effective for a period not to exceed one (1) year, 5. beginning _____________________, 20___, and ending _____________________, 20__. I reserve the right to revoke this authority at any time. OR In the event Section 6 is completed and valid, Section 5 does not apply. I am a parent or legal guardian on active duty as governed by KRS 403.352(10). My 6. active duty service is scheduled to begin on ___________________, 20__, and is estimated to end on __________________________, 20__. 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. 7. BY: ______________________________________________________________ (Parent/Legal Guardian signature) I hereby accept my designation as Attorney-in-fact for the minor child or children 8. specified in this power of attorney. __________________________________________________________ (Attorney-in-fact signature) County of __________________ ACKNOWLEDGMENT 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 Guardian) ______________________________ (Name of Attorney-in-fact), to me known to be the identical persons who executed this instrument and 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 notary public) My commission expires: _________________." (2) The power of attorney is legally sufficient under this section and KRS 403.352 if the wording of the form complies substantially with subsection (1) of this section, the form is properly completed and signed, and the form or parties are not otherwise invalid pursuant to KRS 403.352. Effective: July 15, 2016 History: Created 2016 Ky. Acts ch. 107, sec. 2, effective July 15, 2016.