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I, ______________________________, of , am <br />(Name of affiant) (City) (State) <br />The natural (mother or father) of the following minor child/children: <br /> (Circle one) <br /> born on / / , <br /> born on / / , <br /> born on / / , <br /> born on / / , <br />Pursuant to Idaho Code, section 15-5-104, I do hereby appoint <br />(Enter name of person or agent) <br />of , , my true and lawful attorney in fact, to act <br />(City) (State) <br />on my behalf and escort the above named minor child/children to visit (Enter name of the resident) <br />at an Idaho Department of Correction (IDOC) facility. <br /> This power of attorney is given for vesting temporary custody of said child/children in <br /> and delegating my parental powers during the period <br />(Enter name of person or agent) <br />he/she has temporary custody. <br /> The powers granted will commence and be in force and effect beginning the day of <br /> , 20 , and will remain in force and effect until the day of <br /> , 20 , unless I revoke said power at an earlier date. I reserve the right to revoke this power and delegation at any time. <br /> Dated this day of , 20 <br /> <br />(Custodial parent or legal guardian’s signature) <br />Notary Section <br />State of <br />County of <br />On this day of , 20 , personally appeared before me <br /> , known to me to be the person whose name is subscribed to the <br />(Name of affiant) <br />foregoing instrument, and swore and acknowledged to me that he executed the same for the purpose and in the capacity therein expressed, and that the statements contained therein are <br />true and correct. <br /> <br /> Notary Public for Idaho <br /> Residing at , Idaho <br /> My Commission expires: