Form II "Custodial Statement and Agreement - Third-Party Custody" - Indiana

What Is Form II?

This is a legal form that was released by the Indiana Department of Education - a government authority operating within Indiana. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2017;
  • The latest edition provided by the Indiana Department of Education;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form II by clicking the link below or browse more documents and templates provided by the Indiana Department of Education.

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Download Form II "Custodial Statement and Agreement - Third-Party Custody" - Indiana

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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)
(first)
(mi)
(street)
(city)
(state)
(zip code)
Last school corporation attended:
Current school corporation:
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 parents are living outside the United States and maintain no home in any school corporation.
Parent Information
Name: (last)
(first)
(mi)
(street)
(city)
(state)
(zip code)
Guardian or Custodian Information
Name: (last)
(first)
(mi)
( street )
( city )
( state )
( zip code )
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)
Name (printed)
Signature
Signature
Date
Date
Acknowledged by
on behalf of
(name and title)
(school corporation)
Date
Page 1 of 1
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)
(first)
(mi)
(street)
(city)
(state)
(zip code)
Last school corporation attended:
Current school corporation:
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 parents are living outside the United States and maintain no home in any school corporation.
Parent Information
Name: (last)
(first)
(mi)
(street)
(city)
(state)
(zip code)
Guardian or Custodian Information
Name: (last)
(first)
(mi)
( street )
( city )
( state )
( zip code )
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)
Name (printed)
Signature
Signature
Date
Date
Acknowledged by
on behalf of
(name and title)
(school corporation)
Date
Page 1 of 1