Power of Attorney
I, ______________________________, being of sound mind and body, declare the following:
- That I am the natural mother (father) of ________________________________________________________________.
- That I am presently incarcerated at ________________________________________________________________.
- That, during this time, my ___________________________ is being cared for by _________________________________________.
- That I wish to give full Power of Attorney to ___________________________ with respect to the care and custody of my ____________________________________.
- That, specifically, I give ___________________________ full Power of Attorney with respect to the care and custody of ______________________________ in matters affecting _____ medical needs, schooling, public assistance and Medi-Cal, legal matters, and all other matters pertaining to the well-being of my child.
I declare under penalty of perjury that the preceding statement is true and correct, and that I signed this statement with full knowledge of its contents, this _____ day of _________, 20___, in ____________________, California.
_________________________________
Signature
STATE OF CALIFORNIA )
) SS.
COUNTY OF ____________________)
Subscribed and sworn to before me a notary public this _____ day of __________, 20____.
______________________________
Notary Public
My commission expires:
____________________
1540 Market St., Suite 490 • San Francisco, CA 94102
(415) 255-7036 • info@prisonerswithchildren.org