Utah Minor Child Power of Attorney

I swear that the following is true:
(1)	I am the [  ]  parent  [  ]  court-appointed guardian of ___________________________________________________ (name), who was born on _______________________________ (date).
(2)	I appoint the following person as my attorney-in-fact for the person named in Paragraph (1).
Name		
Address		
City, State, Zip		
Phone		
E-mail		
(Check (3) OR (4), not both. If you check (4), describe the authority being delegated.)
(3)	[  ]  	I delegate to my attorney-in-fact all power and authority that I have as a parent or guardian, except the power to consent to marriage or adoption.
(4)	[  ]  	I delegate to my attorney-in-fact only the specific authority to:

	

(5)	This power of attorney lasts until ____________________________ (date). (This date must be within the next 6 months.)
(6)	[  ]  	This power of attorney lasts even in the event of my disability.

Date		Sign here ►		
Typed or printed name		
Address		
City, State, Zip		
Phone		
E-mail		

On this date, I certify that _________________________________________________________ (name) who is known to me or who presented satisfactory identification, in the form of ______________________________________________________ (form of identification), has, while in my presence and while under oath or affirmation, voluntarily signed this document and declared that it is true.	
Date:		Sign here ►		
Typed or printed name		
Notary Seal