2020 Georgia Code
Title 20 - Education
Chapter 1 - General Provisions
Article 1A - Caregiver Educational Consent
§ 20-1-18. Requirements for Validly Executed Affidavit; Form
- A kinship caregiver's affidavit shall be invalid unless it substantially contains, in not less than ten-point boldface type or a reasonable equivalent thereof, the form set forth in subsection (b) of this Code section. The warning statement shall be enclosed in a box with three-point rule lines.
- The kinship caregiver's affidavit shall be substantially in the following form:
INSTRUCTIONS: Please print clearly.
I hereby certify that the child named below lives in my home and I am 18 years of age or older.
1. Name of child: _______________________________________________________
2. Child's date of birth: _______________________________________________
3. My full name (kinship caregiver giving authorization): _______________
4. My home address: _____________________________________________________
5. [ ] I am a kinship caregiver.
6. I have assumed kinship caregiver status because of one or more of the following circumstances (check at least one):
[ ] A parent being unable to provide care due to the death of the other parent;
[ ] A serious illness or terminal illness of a parent;
[ ] The physical or mental condition of the parent or the child such that proper care and supervision of the child cannot be provided by the parent;
[ ] The incarceration of a parent;
[ ] The loss or uninhabitability of the child's home as the result of a natural disaster;
[ ] A period of active military duty of a parent exceeding 24 months; or
[ ] I am unable to locate a parent or parents at this time to notify them of my intended authorization because (list reasons):
_________________________________________________________________________
_________________________________________________________________________.
7. Names of parent(s) or legal custodian(s): ____________________________
8. Address of parent(s) or legal custodian(s): __________________________
9. Phone numbers and email addresses of parent(s) or legal custodian(s):
_________________________________________________________________________
10. Kinship caregiver's date of birth: __________________________________
11. Kinship caregiver's State of Georgia driver's license number or identification card number: _______________________________________________________
WARNING: DO NOT SIGN THIS FORM IF ANY OF THE STATEMENTS ABOVE ARE INCORRECT OR YOU WILL BE COMMITTING A CRIME PUNISHABLE BY A FINE, IMPRISONMENT, OR BOTH.
I recognize that if I knowingly and willfully make a false statement in this affidavit, I will be guilty of the crime of false swearing.
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