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The form collects basic information for the person with parental authority, the designated caretaker, mailing addresses, and all covered children. It defines authorized health, education, discipline, and shelter actions within the legal mandate and states that the provisional custody expires after one year unless otherwise specified. It includes notarization, witness, and signature blocks for the parties and notary identification.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/provisional-custody-by-mandate-form-louisiana-department-of-health/282914/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/provisional-custody-by-mandate-form-louisiana-department-of-health/282914.png","ImageObject",442,249,{"name":88,"@type":89},"Chumphorn","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-27","2026-09-16",true,{"@type":98,"interactionType":99,"userInteractionCount":8},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What authority does the qualified caretaker relative receive under this provisional custody mandate?","Question",{"text":108,"@type":109},"The qualified caretaker relative is authorized to provide for the child’s health, education, discipline, and shelter as outlined by law on provisional custody by mandate.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How long does the provisional custody agreement last?",{"text":113,"@type":109},"By default, the provisional custody expires in one year unless stated otherwise in the time period section.",{"name":115,"@type":106,"acceptedAnswer":116},"What signing and verification steps are required to complete the form?",{"text":117,"@type":109},"Completion requires signatures from the person with parental authority and the qualified caretaker relative, along with witnesses and a notary declaration, supported by the proof of notarization sections.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},282914,1791007846,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":8,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":79,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":73},2336475401981,"https://ap-avatar.wpscdn.com/avatar/22000c94efd8d5204d?x-image-process=image/resize,m_fixed,w_180,h_180&k=1786935347598174694","KCSP 4K Rev. 06/26  \n03/23 Issue Obsolete  \nLouisiana Department of Health  \nProvisional Custody by Mandate Form  \nBASIC INFORMATION  \nPerson with Parental Authority (1)  \n| Name (First, Last) | Marital status |\n| --- | --- |\n|  |  |\n| Mailing Address\u003Cbr>Person with Parental Authority (2) (if applicable)\u003Cbr>\u003Cbr>Name (First, Last) | |\n|  | Marital status |\n|  |  |\n| Mailing Address\u003Cbr>Children\u003Cbr>List each child covered by this form. Include each child’s first and last name. |  |\n|  |  |\n|  |  |\n|  |  |\n|  |  |\n|  |  |\n| Person Receiving Temporary Custody – Qualified Caretaker Relative\u003Cbr>\u003Cbr>Name (First, Last) |  |\n|  |  |\n\nMailing Address  \nTemporary Custody Responsibilities  \nI, the person with parental authority, grant  provisional custody of the above-named child(ren) . I authorize this person to provide for the health, education, and welfare of the child as outlined by the law on Provisional Custody by Mandate, which includes:  \nPerson(s) with parental authority initials:  \nHealth – I authorize the person with provisional custody to authorize medical care, treatment, or surgery as needed or deemed necessary for the child's health, safety, and wellbeing.  \nEducation – I authorize the person with provisional custody to enroll the child in schools or other educational institutions as needed for the child's education.  \nDiscipline – I authorize the person with provisional custody to discipline the child in a reasonable way, as needed for the child's upbringing, supervision, and training.  \nShelter – I authorize the person with provisional custody todo and perform all other necessary acts for the child's shelter, support, and overall well-being.  \nTime Period  \nI understand that this Provisional Custody expires in one year.  \nBy default, this Provisional Custody expires in one year unless stated otherwise below:  \nMonth Day Year  \nI agree that anyone who gets a copy of this document can trust that the person named as the Qualified Caretaker Relative has the authority to act on my behalf. If I cancel or end this agreement for any reason, it does not affect the third party's ability to rely on the Qualified Caretaker Relative's authority until they are told that the agreement is no longer in place. I agree to pay for any damages or losses that the third party may suffer because they relied on the Qualified Caretaker Relative's authority.  \nPROOF OF NOTARIZATION  \nPerson with Parental Authority (1)  \nThe Qualified Caretaker Relative named above agrees to take temporary care of the children listed in this document. This agreement was made in the City of  ,  \nof , in the Parish/County of  ,  \nin the presence of witnesses who have also signed this document. The agreement has been read in full by all parties involved.  \nI, the notary, am declaring that on the  Month , Day ,  Year , in the presence of the witnesses listed below this document is being signed.  \nPerson with Parental Authority (1)  \nName of person with parental authority Signature of person with parental  \nauthority  \nPerson Receiving Temporary Custody  \nWitnesses  \nNotary  \n\n| Name of person receiving temporary custody |\n| --- |\n|  |\n| Name of witness |\n|  |\n| Name of witness |\n|  |\n\n\n| Signature of person receiving temporary custody |\n| --- |\n|  |\n| Signature of witness |\n|  |\n| Signature of witness |\n|  |\n\nName and title/notary identification number Signature of notary  \nOPTIONAL – If two persons with parental authority are temporarily transferring custody complete the signatures in the next page.  \nPROOF OF NOTARIZATION  \nPerson with Parental Authority (2)  \nThe Qualified Caretaker Relative named above agrees to take temporary care of the children listed in this document. This agreement was made in the City of  ,  \nof , in the Parish/County of  ,  \nin the presence of witnesses who have also signed this document. The agreement has been read in full by all parties involved.  \nI, the notary, am declaring that on the  Month , Day ,  Year , in the presence of the witnesse","cbCaiqYKgMoLHOeF","https://ap.wps.com/l/cbCaiqYKgMoLHOeF","pdf",127583,"English","# BASIC INFORMATION\n## Person with Parental Authority (1)\n## Person with Parental Authority (2) (if applicable)\n## Children\n## Person Receiving Temporary Custody – Qualified Caretaker Relative\n## Mailing Address\n## Temporary Custody Responsibilities\n## Time Period\n## PROOF OF NOTARIZATION\n### Notary and Witnesses (Signature Blocks)\n### OPTIONAL (Two Persons with Parental Authority)","[{\"question\":\"What authority does the qualified caretaker relative receive under this provisional custody mandate?\",\"answer\":\"The qualified caretaker relative is authorized to provide for the child’s health, education, discipline, and shelter as outlined by law on provisional custody by mandate.\"},{\"question\":\"How long does the provisional custody agreement last?\",\"answer\":\"By default, the provisional custody expires in one year unless stated otherwise in the time period section.\"},{\"question\":\"What signing and verification steps are required to complete the form?\",\"answer\":\"Completion requires signatures from the person with parental authority and the qualified caretaker relative, along with witnesses and a notary declaration, supported by the proof of notarization sections.\"}]","Provisional Custody by Mandate Form - Louisiana Department of Health | PDF",1789585034]