Custodial Statement And Agreement Form PDF Details

Ensuring the welfare and educational continuity of students sometimes requires the creation of relationships defined by legal documentation, especially in circumstances where traditional parental support is absent. The Custodial Statement and Agreement form, established by the State Superintendent of Public Instruction and mandated by I.C. 20-26-11-3, serves this precise purpose. It is designed to officially document the transfer of custodial responsibilities from a student's parents to a designated guardian or custodian. This form captures essential information about the student, including their name, address, and the schools they have attended, alongside the reason for requiring third-party custody. Reasons may range from abandonment, parental inability to support, to parents living outside the United States with no local home. Additionally, it details guardian information, signifying their agreement to assume all parental duties toward the student's educational dealings and other related matters. By affirming this agreement, the guardian commits to a legally binding relationship that is only severable through written termination by either party, thereby ensuring a stable and supportive environment for the student's growth. Accuracy and truthfulness in this documentation are underscored by an affirmation under the penalties of perjury, making it a critical component in safeguarding the interests and continuity of education for students in unique living situations.

QuestionAnswer
Form NameCustodial Statement And Agreement Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesindiana education third party custody form, custodial statement and agreement third party custody, form ii third custody, agreement third party custody template

Form Preview Example

FORM II

DOE 11/17

CUSTODIAL STATEMENT AND AGREEMENT:

THIRD-PARTY CUSTODY

This agreement is prepared by the State Superintendent of Public Instruction as required by I.C. 20-26-11-3.

Student Information

 

 

 

 

 

 

 

 

 

 

 

Name: (last)

 

(first)

 

 

 

 

(mi)

 

 

(street)

 

 

(city)

 

(state)

 

(zip code)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last school corporation attended:

 

 

 

 

 

 

 

 

 

 

 

 

Current school corporation:

 

 

 

 

 

 

 

 

 

 

 

 

Indicate the reason for utilization of this form: The student has been abandoned.

The parents are unable to support the student and the student is living with the guardian or custodian, who is

supporting and caring for the student. The student was not placed with the guardian or custodian for the primary purpose of attending school in the school corporation of the guardian’s or custodian’s residence.

The parents are living outside the United States and maintain no home in any school corporation.

Parent Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name: (last)

 

 

 

 

 

(first)

 

 

 

 

 

 

(mi)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(street)

 

 

 

 

(city)

 

 

 

(state)

 

(zip code)

 

 

Guardian or Custodian Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name: (last)

 

 

 

 

 

 

(first)

 

 

 

 

 

 

 

(mi)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(street)

 

 

 

 

(city)

 

 

 

 

(state)

 

 

(zip code)

 

 

 

 

 

 

 

 

agrees to assume all the duties and be subject to all the liabilities of the

(person with whom student will live)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

parent of

with respect to dealing with the school corporation and for all other purposes

 

 

 

(student)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

under Indiana Code 20-26. This agreement is binding from the date signed until terminated by the parent or guardian in writing.

I affirm, under the penalties for perjury, that the foregoing representations are true.

Name (printed)

Signature

Date

Acknowledged by

(name and title)

Name (printed)

Signature

Date

on behalf of

(school corporation)

Date

Page 1 of 1

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Part number 1 in filling out agreement third party custody template

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Part no. 2 of submitting agreement third party custody template

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