Power Of Attorney For Care Of A Minor Child Page 4
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5I/We declare under penalty of perjury under the laws of the State of Tennessee that the
foregoing is true and correct.
STATE OF _____________ )
COUNTY OF __________ )
______________________________
Date: ______________
Mother/Legal Guardian
The Mother/Legal Guardian, ______________________, personally appeared
before me this _____ day of ____________, 20_____.
______________________________
NOTARY PUBLIC
My commission expires:
___________________
STATE OF ____________ )
COUNTY OF __________ )
______________________________
Date: ______________
Father/Legal Guardian
The Father/Legal Guardian, ______________________, personally appeared
before me this _____ day of ____________, 20______.
______________________________
NOTARY PUBLIC
My commission expires:
___________________
STATE OF _____________ )
COUNTY OF __________ )
______________________________
Date: ______________
Caregiver
The Caregiver, ______________________, personally appeared before me this
_____ day of ____________, 20______.
______________________________
NOTARY PUBLIC
My commission expires:
___________________
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