(1) A power of attorney established pursuant to this section, KRS § 403.352, and KRS Chapter 403A 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, KRS § 403.352, and KRS Chapter 403A.
“Power of Attorney for Temporary Delegation of Parental or Legal Custody and Care
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Terms Used In Kentucky Statutes 403.353

  • Attorney: means attorney-at-law. See Kentucky Statutes 446.010
  • Attorney-in-fact: A person who, acting as an agent, is given written authorization by another person to transact business for him (her) out of court.
  • City: includes town. See Kentucky Statutes 446.010
  • Deed: The legal instrument used to transfer title in real property from one person to another.
  • Guardian: A person legally empowered and charged with the duty of taking care of and managing the property of another person who because of age, intellect, or health, is incapable of managing his (her) own affairs.
  • Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases.
  • Power of attorney: A written instrument which authorizes one person to act as another's agent or attorney. The power of attorney may be for a definite, specific act, or it may be general in nature. The terms of the written power of attorney may specify when it will expire. If not, the power of attorney usually expires when the person granting it dies. Source: OCC
  • State: when applied to a part of the United States, includes territories, outlying possessions, and the District of Columbia. See Kentucky Statutes 446.010
  • Statute: A law passed by a legislature.
  • Treatment: when used in a criminal justice context, means targeted interventions
    that focus on criminal risk factors in order to reduce the likelihood of criminal behavior. See Kentucky Statutes 446.010
  • Year: means calendar year. See Kentucky Statutes 446.010

1. I certify that I am the parent or legal guardian of:

(Full name of minor child) (Date of birth)

(Full name of minor child) (Date of birth)

(Full name of minor child) (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)
as the Attorney-in-fact of each minor child named above.
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.
4. I delegate to the Attorney-in-fact the following specific powers and responsibilities
(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.
5. This power of attorney is effective for a period not to exceed one (1) year, 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.
6. I am a parent or legal guardian on active duty as governed by KRS Chapter 403A. My 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)
8. I hereby accept my designation as Attorney-in-fact for the minor child or children 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, KRS § 403.352, and
KRS Chapter 403A 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: June 29, 2021
History: Amended 2021 Ky. Acts ch. 94, sec. 35, effective June 29, 2021. — Created
2016 Ky. Acts ch. 107, sec. 2, effective July 15, 2016.

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