Skip to content

Statement of Adult in Loco Parentis (As a Parent) Fillable PDF

In loco parentis means in the place of a parent or instead of a parent. In order for QIN TANF to decide that you are acting in loco parentis, you must have intentionally taken over the duties of a parent.

QIN TANF considers you as acting in loco parentis when (1) the child’s parents are absent, (2) you are not the child’s legal guardian or custodian and (3) you have taken over the daily care and control of the child.

Below are examples of duties an adult acting in loco parentis will do:

Provide basic food, shelter and clothing for the child.Get the child up and ready in the morning.
Make sure the child gets to school or daycare.Help child bathe and dress (if applicable).
Prepare meals for the child.Attend parent/teacher conferences.
Take the child to regular medical/dental appointments.Act as the emergency contact at school.
Sign up and take the child to extracurricular activities.Provide guidance and discipline to the child.

Child Name(Required)
Name of Adult Caring for the Child(Required)
Physical Address(Required)
Name of Mother
Mother's Current or Last Known Address
Name of Father
Father's Current or Last Known Address
Do you have permission from the child’s parents to care for the child?(Required)
If yes, is it in writing?
Are you planning to seek court-ordered custody or guardianship?(Required)
Duties you will carry out as acting in loco parentis:(Required)
Check All that Apply
I declare under penalty of perjury under the laws of the United States and the State of Washington that the facts contained in this report are true and correct and complete for the entire report month.
MM slash DD slash YYYY

In order to protect your private information the completed PDF form will be encrypted with a password. Please type a memorable password below.

The completed PDF form will be emailed to you please provide an email address below.