NO
TICES:
1. This declaration does not affect the rights of the minor’s parents or legal guardian regarding
t
he care, custody, and control of the minor, and does not mean that the caregiver have legal
custody of the minor.
2. A person who relies on this affidavit has no obligation to make any further inquiry or
investigation.
3. This affidavit is not valid for more than one year after the date on which it is executed.
Additional Information:
TO CAREGIVERS:
1. “Qualified relative,” for purposes of item 4, means a spouse, parent, stepparent, brother,
sister, stepbrother, stepsister, half-brother, half-sister, uncle, aunt, nephew, first cousin, o
r
any per
son denoted by the prefix “grand” or “great,” or the spouse of any of the persons
specified in this definition, even after the marriage has been terminated by death or
dissolution.
2. The law may require you, if you are not a relative or a currently licensed foster parent, to
obt
ain a foster home license in order to care for a minor. If you have any questions, please
contact your local department of social services.
3. If the minor stops living with you, you are required to notify any school, health care provider,
or health care service plan to which you have given this affidavit.
4. If you do not have the information requested in item 9 (California driver’s license or I.D.),
pr
ovide another form of identification such as your social security number or Medi-Ca
l
num
ber.
TO SCHOOL OFFICIALS:
1. Section 48204 of the Education Code provides that this affidavit constitutes a sufficient basis
for determination of residency of the minor, without the requirement of a guardianship or other
custody order, unless the school determines from actual facts that the minor is not living with
the caregiver.
2. The school may require additional reasonable evidence that the caregiver lives at the
addr
ess provided in item 5.
TO HEALTH CARE PROVIDERS AND HEALTH CARE SERVICE PLANS:
1. No person who acts in good faith reliance upon a caregiver’s authorization affidavit to
provide medical or dental care, without actual knowledge of facts contrary to those stated o
n
t
he affidavit, is subject to criminal liability or to civil liability to any person, or is subject t
o
pr
ofessional disciplinary action, for such reliance if the applicable portions of the form are
completed.
2. This affidavit does not confer dependency for health care coverage purposes.
