Affidavit D State Of North Carolina (Page 2 of 2) in pdf

Affidavit D State Of North Carolina Page 2

If any of the above circumstances/information changes the undersigned individuals agree to

notify the school principal immediately.

Sworn Under Oath or Affirmation.

________________________________________________

Signature of Responsible Adult

Address and Phone Numbers for Responsible Adult:

Mailing Address: _____________________________________

•

_____________________________________

Phone numbers:

•

Daytime

________________________________

Evening

________________________________

Cell

________________________________

SWORN TO AND SUBSCRIBED BEFORE ME

This _____ day of ______________, 20_____.

by________________________________________

(Name of Responsible Adult)

____________________________________

(Signature of Notary Public)

My Commission Expires:________________

(Notary Seal)

Sworn Under Oath or Affirmation.

________________________________________________

(Signature of Individual or Government Agency Rep.)

SWORN TO AND SUBSCRIBED BEFORE ME

This _____ day of ______________, 20_____.

By ________________________________________

(Name of Individual or Agency Representative)

on behalf of _________________________________

(Name of Government Agency)

___________________________________

(Signature of Notary Public)

My Commission Expires:________________

(Notary Seal)

R&S 534656-1

Henderson County Public Schools 7.16.07dlj

Affidavit D State Of North Carolina Page 2