Durable Power Of Attorney For Minor Child - Iowa Legal Aid Page 3
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4 I authorize my Agent to sign, on behalf of the child(ren), any papers needed to
implement health care decisions.
4.
Effective date and durability (Check all that apply.)
This Power of Attorney is effective (check one)
___ a. starting on
.
___ b. whenever I am unable or unavailable to make decisions or care for my
minor child(ren) listed.
This Power of Attorney shall not be affected by my disability.
I may revoke this Power of Attorney by providing written notice to my Agent.
If not revoked, it shall be effective (check one)
___ c. until
.
___ d. my death.
My Agent shall not be liable for an error in judgment made in good faith, but shall only
be liable for willful misconduct or breach of good faith.
5.
Signature
________________________
_____________________________________
Parent’s signature
Date
_____________________________________
Parent’s printed name
Address: _____________________________
City/State/Zip: _________________________
STATE OF IOWA, COUNTY OF _________________________ ) ss:
This instrument signed and acknowledged before me on this _______ day of
_______________, 20____, by ________________________________.
Parent’s name
_____________________________________
NOTARY PUBLIC FOR THE STATE OF IOWA
This form was developed by:
IOWA LEGAL AID
520 NEBRASKA ST #337
SIOUX CITY, IA 51101
800-352-0017
FAX 712-277-2554
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