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PARISH OF
BY: STATE OF LOUISIANA
TO: UNITED STATES OF AMERICA
PROVISIONAL CUSTODY BY MANDATE: LSA-R.S. 9:954
BE IT KNOWN, that on this day of , 20 , before me, the
undersigned notary, and in the presence of the undersigned competent witnesses, personally came
and appeared:
Name(s) of affiant(s):
Marital status of affiant(s):
Address of affiant(s):
who avers that he/she is: ( ) parent(s); or if divorced or separated, the ( ) natural tutor/tutrix, or (
) legal custodian; or ( ) natural co-tutor/co-tutrix.
of the following minor children:
Name: Date of birth: / /
Name: Date of birth: / /
Name: Date of birth: / /
Who, by these presents, does make, name, constitute, and appoint:
Name of Agent(s)
Address of Agent(s)
and grants 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 her due and proper education.
(3) Discipline the child in such reasonable manner as may be necessary for him/her 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 revoked 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 here 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 or she has actual
knowledge thereof. I agree to indemnify and hold harmless the third party for any claims that arise
against him or her because of reliance on this Provisional Custody by Mandate.
The undersigned agent does hereby accept the provisional custody of the child(ren) named
herein as specifically provided above.
THUS DONE AND PASSED on this day of , 20 in
the City of , State of Louisiana, in the presence of, and, competent
witnesses below, who sign these presents with the appearers and me, notary, after due reading of the
whole.
WITNESSES:
(Parent/Tutor/Tutrix/Legal Custodian)
(Agent)
NOTARY PUBLIC