Residency Affidavit Form
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Residency Affidavit Form
Reason for Affidavit use, please check one:
______ Financial
______ Medical
______ Legal
______ Temporary
Residency Verification must be complete before a student can enroll at his/her assigned school.
Check one:
New to District
Returning Student on Residency Affidavit form
Identifying Information – please print
This form is to be completed by the student’s parent or legal guardian and Homeowner/Leaseholder AND a
Please review page two for supporting documentation needed
Notary Public.
.
A. Student Information: (Provide First, Middle and Last name of each Student.)
Student’s Name: ______________________________ DOB: _____________ School: _________________
Student’s Name: ______________________________ DOB: _____________ School: _________________
Student’s Name: ______________________________ DOB: _____________ School: _________________
Student’s Name: ______________________________ DOB: _____________ School: _________________
B. Student Lives with: Print name(s): ______________________________________________________
Parent/Guardian’s Phone ____________________ Relationship to the Student ____________________
C. Primary Homeowner/Leaseholder Address: PLEASE NOTE THAT POST OFFICE BOX IS NOT ACCEPTABLE AS A
RESIDENCE ADDRESS.
Homeowner/Leaseholder’s Name (please print) _____________________________________________
Address _____________________________________________________________________________
Street Address
City
State
Zip
Homeowner/Leaseholder’s Phone Number ________________________________________________
I declare, under the penalty of perjury, that the above named student(s) reside(s) with me at the above
address. I also agree to notify the district within two (2) weeks when residency has been changed. I
understand that a new affidavit and a new proof of residency must be submitted.
Falsification of an information or document required for residency verification or the use of the address of
another person without actually residing there may result in the revocation of student enrollment.
________________________________________ ___
_________________
Homeowner/Leaseholder Signature
Date
________________________________________ ___
_________________
Parent/Guardian Signature
Date
Subscribed and sworn before me on this _______ day of ______________________, 20 ____.
_________________________________
(Place Notary Seal or Stamp below)
NOTARY PUBLIC SIGNATURE
_______________________________
SCHOOL OFFICIAL SIGNATURE
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