How to Fill Out a Minnesota Parental Delegation Form.

Blue Question Mark ManThe Minnesota parental delegation form is available to all parents who need to temporarily delegate the care of children to another trusted adult.  The form is simple, but care should be taken to complete it with full names and properly witnessed signatures. The Minnesota parental delegation does not grant custody.  The delegation appoints someone to share caregiving with a parent while that parent is  unavailable for some reason.  The delegation can be terminated by the delegating parent at anytime. The completed delegation does not have to be filed with the Court.  The completed form can be copied and given to the children’s school and healthcare providers or anyone else needing proof of the delegation.

For more information and to read the Minnesota Statute see Delegation of Power by Parent or Guardian



[Minn. Stat. § 524.5-211]


County of    [ where signed and notarized]


I/We, [ Parties giving the delegation] of the County of [ parties residential County], State of Minnesota, am/are the parent(s) of: Child/ Children Name(s): [ Complete names of child or children– full first, middle, and last name ] who were born on: [ child or children’s dates of birth; make certain to identify which child has what birthday]

  1. I/We hereby appoint the following person(s): [ Full and complete name of the person or persons to whom you are delegating who are called the attorneys-in-fact; you can name one person or more]

of the County of [the person or persons residential county] State of Minnesota, to be my/our true and lawful Attorney(s) in Fact for the exercise of parental over my/our child/children for a period of [ how long will the delegation be in place- cannot exceed one year] from and after the date of execution of this document to and including the following date[ the last effective date of the delegation ] pursuant to Minn. Stat. § 524.5-211.

The named Attorney(s) in Fact are related to me/us or I/we know her/him as follows: [ Who are the attorneys-in-fact to you? E.g., a brother, sister, mother, father, best friend, et….]

  1. This Power of Attorney hereby constitutes my/our delegation to my/our Attorney(s) in Fact of all of my/our parental powers and authority regarding the care, custody, and property of my/our child/children, including, but not limited to, the authority to: (a) authorize medical treatment; (b) enroll my/our child/children in school; and, (c) to provide a home, care, and supervision of my/our child/children at my/our Attorney(s) in Fact’s home. This Power of Attorney does not authorize my Attorney(s) in Fact to consent to marriage or adoption of my/our child/children named herein. For Single Parents Only: I understand that I am legally obligated, pursuant to Minn. Stat. § 524.5-505(b), to mail or give a copy of this document to any other parent within 30 days of its execution unless: (a) the other parent does not have visitation rights or has supervised visitation rights; or, (b) there is an existing order for protection under chapter 518B or similar law of another state in effect against the other parent to protect me. [ The forgoing is Minnesota law language and should not be modified. This  paragraph lists all of the powers that you are giving to the attorney-in-fact in caring for your child. SINGLE PARENTS: Be sure to follow the notice requirements to the other parent.  Note the exceptions for the notice. ]


THE NEXT SECTION IS THE SIGNATURE SECTION.  [ Be certain to sign your name the same way that you listed your name above.  Full and complete names should be included for the parent or parents granting the delegation; the attorney(s)-in-fact and the children.  All persons must sign in the presence of a notary.]

IN TESTIMONY WHEREOF, I have hereunto set my hand this:        day of _________ 20_____________________________________________________

Signature of Parent

IN TESTIMONY WHEREOF, I have hereunto set my hand this:        day of _________ 20______.___________________________________

Signature of Parent

I/We, the undersigned Attorney(s) in Fact hereby accept the foregoing Delegation of Parental Authority.


Signature of Attorney in Fact


Signature of Attorney in Fact

The above-named persons known to me appeared and having been first duly sworn subscribed before me on this_________   day of _______________ 20___.


_______________________ [ All signatures must be notarized!]



For a blank Minnesota Delegation form see:  Minnesota Parental Delegation of Power

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Kate Willmore, Saint Cloud, Minnesota, Divorce, Father’s Rights, Mother’s Rights, Family Lawyer, Family Court Lawyer and Mediation Coach

Call me at (320) 492-3606 or e-mail me via

Copyright 2015

About Kate Willmore, Esq.

Kate Willmore, Saint Cloud, Minnesota, divorce, custody and family attorney brings over 25 years experience to every client's legal matter. *** Licensed in Minnesota and in California

4 Responses to “How to Fill Out a Minnesota Parental Delegation Form.”

  1. Thanks for this – my question is: do you need an attorney present? What is “Signature of Attorney in Fact”?


  2. You don’t need to file this or bring it anywhere for the action of delegation to be complete?


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