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ILLINOIS STATE BOARD OF EDUCATION

AFFIDAVIT OF ENROLLMENT AND RESIDENCY

This affidavit form may be used if you are an adult who has assumed responsibility for a pupil and provide the pupil with a fixed, night-

time abode, for reasons other than access to the educational programs of the school district.

This form should not be used, however, if you are the natural or adoptive parent of the pupil, have been granted court-ordered custody

or guardianship, or are receiving public aid on behalf of the pupil. For these situations, you are only required to provide documentation

(such as a birth certificate or court order), without the need of an affidavit like this one.

This form is also not required for pupils who are sharing the housing of others due to lack of housing, economic hardship, or similar

reason, or are otherwise homeless as defined in state and federal law. Homeless pupils must be enrolled immediately.

If you have any questions about residency, including homelessness, please contact the Illinois State Board of Education’s Educator and

School Development Division at (217) 782-2948.

I, _________________________________, reside at _______________________________________________________________,

Name of Adult

Address

which is located within the boundaries of ________________________________________________________________________.

School District

Provide the appropriate information and check each of the following:

I am at least 18 years of age.

I have provided proof in the form(s) of ____________________________________________________________________

Proof of Residency

__________________________________________________________________________________________________

that I am a resident of _________________________________________________________________________________.

School District

I have assumed and exercise responsibility for _____________________________________________________________.

Name of Pupil

I provide a fixed, night-time abode for ____________________________________________________________________.

Name of Pupil

__________________________________ is not living with me for the purpose of having access to the educational programs

Name of Pupil

of the school district.

I understand that knowingly or willfully providing false information to a school district regarding the residency of a pupil for

the purpose of enabling that pupil to attend any school in that district without the payment of nonresident tuition is a Class C

misdemeanor.

I understand that knowingly enrolling or attempting to enroll a pupil in the school of a school district of a tuition free basis

when I know that pupil to be nonresident of the school district, unless the nonresident pupil has a lawful right to attend, is a

Class C misdemeanor.

_________________________

____________________________________

______________________________________

Date

Signature of Adult

Adult (Print Name)

_________________________

____________________________________

_____________________________________

Date

School District Employee (Signature)

School District Employee (Print Name)

ISBE 85-51 (8/09)

Form Isbe 85-51 Affidavit Of Enrollment And Residency - Illinois State Board Of Education

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