Get Custodial Statement 2017-2024

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 street Last school corporation attended Current school corporation first city state mi zip code 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. Parent Information Guardian or Custodian Information 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 on behalf of name and title school corporation Page 1 of 1. C. 20-26-11-3. Student Information Name last street Last school corporation attended Current school corporation first city state mi zip code 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 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. Parent Information Guardian or Custodian Information 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. Parent Information Guardian or Custodian Information 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. 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 on behalf of name and title school corporation Page 1 of 1. C. 20-26-11-3. Student Information Name last street Last school corporation attended Current school corporation first city state mi zip code 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. Parent Information Guardian or Custodian Information 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. .