Free 52727.FH11 - Indiana

STATEMENT OF ATTESTATION BY RELATIVE REGARDING RELATIONSHIP
State Form 52727 (12-06) / CW 2118 DEPARTMENT OF CHILD SERVICES

INSTRUCTIONS:

1. Person requesting placement of a minor relative(s) must complete this statement. 2. Submit white copy to the Department of Child Services (DCS). 3. Keep the canary copy.

AFFIRMATION

I, ____________________________________________________________ hereby affirm that I am the
Name of person requesting placement

____________________________________ of ________________________________________________.
Relationship Name of relative child

I understand that this is a legal document and that any false statements are subject to immediate removal of the child from my home and to criminal prosecution.

CERTIFICATION

I, ____________________________________________________________ hereby certify, under the penalties of perjury, that I am the above-named relative, that I have personally prepared the foregoing statement and that the same is true to the best of my knowledge and belief.

RELATIVE
Signature of relative Date (month, day, year)

Printed name of relative

Address of relative (number and street, city, state, and ZIP code)

DCS FAMILY CASE MANAGER
Signature of Family Case Manager Date (month, day, year)

Printed name of Family Case Manager

DISTRIBUTION:

White - DCS; Canary - Applicant