DSHS Form 14-436 "Statement of Adult Acting in Loco Parentis (As a Parent)" - Washington

What Is DSHS Form 14-436?

This is a legal form that was released by the Washington State Department of Social and Health Services - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2021;
  • The latest edition provided by the Washington State Department of Social and Health Services;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of DSHS Form 14-436 by clicking the link below or browse more documents and templates provided by the Washington State Department of Social and Health Services.

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Download DSHS Form 14-436 "Statement of Adult Acting in Loco Parentis (As a Parent)" - Washington

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TANF/SFA FOR CHILDREN LIVING WITH UNRELATED ADULTS
Statement of Adult Acting in Loco Parentis (as a Parent)
Fill out this form if you are caring for a needy child you are not related to and you do not have
court-ordered custody or guardianship of the child.
SECTION 1. AGENCY INFORMATION (COMPLETED BY AGENCY STAFF ONLY)
1. COMMUNITY SERVICES OFFICE (CSO)
2. CASE MANAGER NAME
3. UNRELATED ADULT’S CLIENT ID NUMBER
SECTION 2. INFORMATION ON ADULT CARING FOR THE CHILD (PLEASE PRINT CLEARLY)
4. LAST NAME
5. FIRST NAME
6. MIDDLE NAME
7. PHONE NUMBER (INCLUDE AREA CODE)
(
)
8. CURRENT ADDRESS (STREET, CITY, AND ZIP CODE)
9. PREVIOUS ADDRESS (STREET, CITY, AND ZIP CODE)
SECTION 3. INFORMATION ON THE CHILD’S PARENTS (PLEASE PRINT CLEARLY)
10. NAME OF CHILD’S MOTHER
11. MOTHER’S PHONE NUMBER
12. MOTHER’S CURRENT OR LAST KNOWN ADDRESS
(
)
13. NAME OF CHILD’S FATHER
14. FATHER’S PHONE NUMBER
15. FATHER’S CURRENT OR LAST KNOWN ADDRESS
(
)
SECTION 4. INFORMATION ABOUT YOUR RELATIONSHIP WITH THE CHILD (PLEASE PRINT CLEARLY)
16. Do you have permission from the child’s parents to care for the child?
Yes
No If yes, is it in w riting?
Yes
No
17. EXPLAIN HOW THE CHILD CAME TO LIVE WITH YOU
18. How long do you expect the child to live w ith you?
19. Are you planning to seek court-ordered custody or guardianship?
Yes
No
SECTION 5. INFORMATION ABOUT THE CARE AND CONTROL OF A CHILD
"In loco parentis" means in the place of a parent or instead of a
We consider you as acting in loco parentis w hen:
parent. In order for the department to decide that you are acting
The child's parents are absent.
in loco parentis, you must have intentionally taken over the duties
You are not the child's legal guardian or custodian;
of a parent.
and
You have taken over the daily care and control of the
child.
Below are exam ples of duties an adult acting in loco parentis w ill do. By signing this form , you are stating that you carry out
the daily care and control of the child and act in loco parentis.
Provide basic food, shelter, and clothing for the
Attend parent/teacher conferences.
child.
Take the child to regular medical or dental appointments.
Get the child up and ready in the morning.
Act as the emergency contact at school.
Make sure the child gets to school or daycare.
Sign up and take the child to extracurricular activities.
Help younger children bathe and dress.
Provide guidance and discipline to the child.
Prepare meals for the child.
By signing this form, I state that I provide care and instructions w ith the child's best interest in mind. I know the department w ill conduct
a background check to decide if there is a reason that the child may not continue to get benefits w hile living w ith me. I understand that
the child cannot receive benefits w hile they live w ith me if I do not meet the requirements for an in-home/relative child care provider
under WAC 110-15-4570. I also know that if the results of the background check raise concerns about the child's health, safety, or
w elfare, the department w ill make a referral to Child Protective Services (CPS) and release the results of this check. I know that if I
give incorrect information on this form on purpose, the law s of the State of Washington consider it perjury.
SIGNATURE OF ADULT ACTING IN LOCO PARENTIS
DATE
DSHS 14-436 (REV. 02/2021)
TANF/SFA FOR CHILDREN LIVING WITH UNRELATED ADULTS
Statement of Adult Acting in Loco Parentis (as a Parent)
Fill out this form if you are caring for a needy child you are not related to and you do not have
court-ordered custody or guardianship of the child.
SECTION 1. AGENCY INFORMATION (COMPLETED BY AGENCY STAFF ONLY)
1. COMMUNITY SERVICES OFFICE (CSO)
2. CASE MANAGER NAME
3. UNRELATED ADULT’S CLIENT ID NUMBER
SECTION 2. INFORMATION ON ADULT CARING FOR THE CHILD (PLEASE PRINT CLEARLY)
4. LAST NAME
5. FIRST NAME
6. MIDDLE NAME
7. PHONE NUMBER (INCLUDE AREA CODE)
(
)
8. CURRENT ADDRESS (STREET, CITY, AND ZIP CODE)
9. PREVIOUS ADDRESS (STREET, CITY, AND ZIP CODE)
SECTION 3. INFORMATION ON THE CHILD’S PARENTS (PLEASE PRINT CLEARLY)
10. NAME OF CHILD’S MOTHER
11. MOTHER’S PHONE NUMBER
12. MOTHER’S CURRENT OR LAST KNOWN ADDRESS
(
)
13. NAME OF CHILD’S FATHER
14. FATHER’S PHONE NUMBER
15. FATHER’S CURRENT OR LAST KNOWN ADDRESS
(
)
SECTION 4. INFORMATION ABOUT YOUR RELATIONSHIP WITH THE CHILD (PLEASE PRINT CLEARLY)
16. Do you have permission from the child’s parents to care for the child?
Yes
No If yes, is it in w riting?
Yes
No
17. EXPLAIN HOW THE CHILD CAME TO LIVE WITH YOU
18. How long do you expect the child to live w ith you?
19. Are you planning to seek court-ordered custody or guardianship?
Yes
No
SECTION 5. INFORMATION ABOUT THE CARE AND CONTROL OF A CHILD
"In loco parentis" means in the place of a parent or instead of a
We consider you as acting in loco parentis w hen:
parent. In order for the department to decide that you are acting
The child's parents are absent.
in loco parentis, you must have intentionally taken over the duties
You are not the child's legal guardian or custodian;
of a parent.
and
You have taken over the daily care and control of the
child.
Below are exam ples of duties an adult acting in loco parentis w ill do. By signing this form , you are stating that you carry out
the daily care and control of the child and act in loco parentis.
Provide basic food, shelter, and clothing for the
Attend parent/teacher conferences.
child.
Take the child to regular medical or dental appointments.
Get the child up and ready in the morning.
Act as the emergency contact at school.
Make sure the child gets to school or daycare.
Sign up and take the child to extracurricular activities.
Help younger children bathe and dress.
Provide guidance and discipline to the child.
Prepare meals for the child.
By signing this form, I state that I provide care and instructions w ith the child's best interest in mind. I know the department w ill conduct
a background check to decide if there is a reason that the child may not continue to get benefits w hile living w ith me. I understand that
the child cannot receive benefits w hile they live w ith me if I do not meet the requirements for an in-home/relative child care provider
under WAC 110-15-4570. I also know that if the results of the background check raise concerns about the child's health, safety, or
w elfare, the department w ill make a referral to Child Protective Services (CPS) and release the results of this check. I know that if I
give incorrect information on this form on purpose, the law s of the State of Washington consider it perjury.
SIGNATURE OF ADULT ACTING IN LOCO PARENTIS
DATE
DSHS 14-436 (REV. 02/2021)
DSHS 14-436 (REV. 02/2021)
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