2013 Louisiana Laws
Revised Statutes
TITLE 9 - Civil Code-Ancillaries
RS 9:954 - Statutory form

§954. Statutory form

The following is a suggested form which may be used by a parent, natural tutor, tutrix, or cotutors acting jointly, or a grandparent awarded custody, to confer the power of provisional custody for the care, custody, and control of the named minor child as authorized herein:

PROVISIONAL CUSTODY BY MANDATE

STATE OF LOUISIANA

PARISH OF ___________________

BE IT KNOWN THAT on this ___ day of __________, 20___, before me, the undersigned notary, and in the presence of the competent witnesses hereinafter named and undersigned:

Personally came and appeared:

(affiant's name, marital status, and mailing address), who is the (parent(s), or, in the event of divorce, separation, or illegitimacy, the natural (co)tutor or tutrix), or grandparent awarded custody of (minor child(ren)) who, by these presents make, name, constitute, and appoint (agent's name and mailing address) and grant provisional custody of the above named child(ren), to provide for the health, education, and welfare of the child as provided by the law on Provisional Custody by Mandate, specifically including the authority to:

INITIAL ALL APPLICABLE PROVISIONS:

____ (1) Consent to and authorize such medical care, treatment, or surgery as may be deemed necessary for the health, safety, and welfare of the child.

____ (2) Enroll the child in such schools or educational institutions as may be deemed necessary for his due and proper education.

____ (3) Discipline the child in such reasonable manner as may be necessary for his proper rearing, supervision, and training.

____ (4) Do and perform all other such acts as may be necessary for the shelter, support, and general welfare of the child.

This Provisional Custody by Mandate will continue to be effective until ___________, 20 __, or one year from date hereof, whichever period is shorter.

I agree that any third party who receives a copy of this document may rely upon the authority granted the agent as indicated herein and may act in reliance on such authority. Revocation or termination by operation of law is not effective as to a third party until he has actual knowledge thereof. I agree to indemnify and hold harmless the third party for any claims that arise against him because of reliance on this Provisional Custody by Mandate.

The undersigned agent does hereby accept the provisional custody of the children named herein.

THUS DONE AND PASSED at _________________, state of ________________, in the presence of _____________ and _____________, competent witnesses, who sign these presents with the appearers and me, notary, after due reading of the whole.

WITNESSES:

______________________

____________________________________

(Parent, Tutor, Tutrix, or Grandparent awarded custody)

______________________

____________________________________

(Other parent, Cotutor, or Grandparent

awarded custody)

_____________________________

(Agent)

_________________________

NOTARY PUBLIC

Acts 1992, No. 304, §2; Acts 1995, No. 235, §1; Acts 2010, No. 171, §1.