475.604.  Delegation form, contents. — Any form for the delegation of powers authorized under section 475.602 shall be witnessed by a notary public and contain the following information:

Terms Used In Missouri Laws 475.604

  • following: when used by way of reference to any section of the statutes, mean the section next preceding or next following that in which the reference is made, unless some other section is expressly designated in the reference. See Missouri Laws 1.020
  • Guardian: one appointed by a court to have the care and custody of the person of a minor or of an incapacitated person. See Missouri Laws 475.010
  • Minor: any person who is under the age of eighteen years. See Missouri Laws 475.010
  • Parent: the biological or adoptive mother or father of a child whose parental rights have not been terminated under Missouri Laws 475.010
  • Property: includes real and personal property. See Missouri Laws 1.020
  • Treatment: the prevention, amelioration or cure of a person's physical and mental illnesses or incapacities. See Missouri Laws 475.010

 (1)  The full name of any child for whom parental and legal authority is being delegated;

 (2)  The date of birth of any child for whom parental and legal authority is being delegated;

 (3)  The full name and signature of the attorney-in-fact;

 (4)  The address and telephone number of the attorney-in-fact;

 (5)  The full name and signature of the parent or legal guardian;

 (6)  One of the following statements:

 (a)  “I delegate to the attorney-in-fact all of my power and authority regarding the care, custody, and property of each minor child named above including, but not limited to, the right to enroll the child in school, inspect and obtain copies of education and other records concerning the child, the right to give or withhold any consent or waiver with respect to school activities, medical and dental treatment, and any other activity, function, or treatment that may concern the child.  This delegation shall not include the power or authority to consent to marriage or adoption of the child, the performance or inducement of an abortion on or for the child, or the termination of parental rights to the child.”; or

 (b)  “I delegate to the attorney-in-fact the following specific powers and responsibilities (insert list).  This delegation shall not include the power or authority to consent to marriage or adoption of the child, the performance or inducement of an abortion on or for the child, or the termination of parental rights to the child.”; and

 (7)  A description of the time for which the delegation is being made and an acknowledgment that the delegation may be revoked at any time.