Verification Of Residency Form

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BANGOR SCHOOL DEPARTMENT
Verification of Residency
This certification form is required as part of the registration process for all students
Two forms of proof of residency will be required.
Name of School:
_______________________________________________________________
Name of Student:
_______________________________________________________________
Last Name
First Name
Middle Initial
Residence:
_________________________________________________
___________
House #
Street
Apt. #
Zip Code
Check here if student is homeless or living in a shelter
Date of Birth
______________________________
Month/Day/Year ex. 01/22/2002
I understand that a minor student is eligible to attend the Bangor Public Schools if his or her parent or
guardian with legal custody resides in Bangor. I hereby certify that I reside in Bangor at the address
shown above; that I have legal custody of this student; and that I am this student’s:
Please check relationship below:
Parent
Legal Guardian
Other Relationship ________________________________________________
Please specify
I agree to notify school authorities of any change of address without delay.
Signed under the pains and penalties of perjury this _______ day of _______________, ___________
Date
Month
Year
_____________________________________
______________________________________
Print Name
Signature
Below for Official School Use Only
Types of residency proof required.
Maine driver’s license # _______________________
Please check two.
Utility receipt dated __________________________
Real estate tax bill dated ______________________
Rental lease dated ___________________________
Excise tax receipt dated _______________________
Other documentation ________________________
(Please attach a copy of the documentation)
Date: _______________________
___________________________________________
School staff person accepting proof of residency

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