(2) “Informal kinship care” means a living arrangement in which a relative of a child, who is not in the care, custody, or guardianship of the local department of social services, provides for the care and custody of the child due to a serious family hardship.

(3) “Relative” means an adult related to the child by blood or marriage within the fifth degree of consanguinity.

(4) “Serious family hardship” means:

(1) A court has not appointed a guardian for the child or awarded custody of the child to an individual other than the relative providing informal kinship care; and

(2) The relative verifies the informal kinship care relationship through a sworn affidavit that:

(1) The name and date of birth of the child;

(2) The name and address of the child's parent or legal guardian;

(3) The name and address of the relative providing informal kinship care;

(4) The date the relative assumed informal kinship care;

(5) The nature of the serious family hardship and why it resulted in informal kinship care; and

(6) The kinship relation to the child of the relative providing informal kinship care.

(1) I, the undersigned, am over eighteen (18) years of age and competent to testify to the facts and matters set forth herein.

(2) __________ (name of child), whose date of birth is __________, is living with me because of the following serious family hardship (check each that is applicable):

___ Death of father/mother/legal guardian

___ Serious illness of father/mother/legal guardian

___ Drug addiction of father/mother/legal guardian

___ Incarceration of father/mother/legal guardian

___ Abandonment by father/mother/legal guardian

___ Assignment of father/mother/legal guardian to active military duty

(3) The name and last known address of the child's parent(s) or legal guardian is:

(4) My kinship relation to the child is __________

(5) My address is:

Street Apt. No.

City State Zip Code

(6) I assumed informal kinship care of this child for 24 hours a day and 7 days a week on __________ (day/month/year).

(7) The name and address of the school that the child attends is:

(8) I solemnly affirm under the penalties of perjury that the contents of the foregoing are true to the best of my knowledge, information, and belief.