DSS Form 37117 "Guardianship/In Loco Parentis Verification" - South Carolina

What Is DSS Form 37117?

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

Form Details:

  • Released on October 1, 2014;
  • The latest edition provided by the South Carolina Department of Social Services;
  • 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 DSS Form 37117 by clicking the link below or browse more documents and templates provided by the South Carolina Department of Social Services.

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Download DSS Form 37117 "Guardianship/In Loco Parentis Verification" - South Carolina

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South Carolina Department of Social Services
SC Voucher Program
GUARDIANSHIP/IN LOCO PARENTIS VERIFICATION
Guardian’s Name:
Address:
Home Telephone:
Work Telephone:
Date:
I am currently providing care for the child or children listed below. The child or children live with me, but the child’s or
children’s parents do not. I am responsible for their care in all aspects of daily living.
Child(ren)’s Names:
Please give a brief explanation, including the parent’s whereabouts, if known, as to why you are responsible for the care
of this child or children. Or you may attach a copy of any legal guardianship papers you have.
Do you receive other benefits for this child? Check all that apply:
n
n
n
n
Food Stamps?
Yes
No
n
n
n
n
Medicaid?
Yes
No
n
n
n
n
TANF?
Yes
No
NOTE: This form must be notarized.
Signature of Guardian
Date
State of South Carolina County of
.
Sworn to and subscribed before me, on this
, day of
, 20
.
Signature of Notary Public
(Printed Name of Notary Public), Notary Public
My commission expires:
DSS Form 37117 (OCT 14) Edition of NOV 09 is obsolete.
South Carolina Department of Social Services
SC Voucher Program
GUARDIANSHIP/IN LOCO PARENTIS VERIFICATION
Guardian’s Name:
Address:
Home Telephone:
Work Telephone:
Date:
I am currently providing care for the child or children listed below. The child or children live with me, but the child’s or
children’s parents do not. I am responsible for their care in all aspects of daily living.
Child(ren)’s Names:
Please give a brief explanation, including the parent’s whereabouts, if known, as to why you are responsible for the care
of this child or children. Or you may attach a copy of any legal guardianship papers you have.
Do you receive other benefits for this child? Check all that apply:
n
n
n
n
Food Stamps?
Yes
No
n
n
n
n
Medicaid?
Yes
No
n
n
n
n
TANF?
Yes
No
NOTE: This form must be notarized.
Signature of Guardian
Date
State of South Carolina County of
.
Sworn to and subscribed before me, on this
, day of
, 20
.
Signature of Notary Public
(Printed Name of Notary Public), Notary Public
My commission expires:
DSS Form 37117 (OCT 14) Edition of NOV 09 is obsolete.