.......................... ..............................
(Date) (Designator's signature)
.......................... ..............................
(Witness's signature) (Witness's signature)
.......................... ..............................
(Number and Street) (Number and Street)
.......................... ..............................
(City, State and Zip Code) (City, State and Zip Code)
If applicable: I, ....................................... ,
(Insert name of other parent)
hereby consent to this designation.
.......................... ..............................
(Date) (Signature of other parent)
..........................................................
(Address of other parent)
I, .......................................................
(Insert name of temporary guardian) hereby accept my
nomination as temporary guardian of ......................
..........................................................
(Insert minor(s)'s name(s)). I understand that my rights and
responsibilities toward the minor child(ren) named above will
become effective upon ......................... (Date)
I further understand that in order to continue as temporary
guardian for the child(ren), I must file a petition with the
court of common pleas within 30 days of the order granting
the petition for temporary guardianship.
.......................... ..............................
(Date) (Signature of temporary guardian)
NOTARY SEAL
I hereby revoke the above temporary guardianship agreement.
20170HB1539PN1996 - 7 -
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