SUSQUEHANNA TOWNSHIP SCHOOL DISTRICT
SWORN STATEMENT BY RESIDENT UNDER §13-1302
(TO BE COMPLETED BY RESIDENT ONLY)
Instructions: Please complete the following statement. If the potential student is living, or will be
living, in a household with two resident adults who will assume responsibility for the student, both
residents must complete and sign this statement.
1. Your Name __________________________ Name of Spouse ______________________________
Home Address ______________________________________________________________________
Home Telephone Number ________________________ Work Number ________________________
Is residency affidavit attached? Yes ______ No ______
2. Child’s Full Name _________________________________________________________________
Birth Date__________________________________ Grade __________________________________
Name & Address of Last School Attended ________________________________________________
Date child began/will begin to reside in your home? ________________________________________
3. Do you intend to keep and support the child continuously and not merely through the school term?
Yes ______ No ______
4. Will anyone contribute to the child’s support? Yes ______ No ______
If yes, explain. ______________________________________________________________________
5. Is there currently a support order for the child that has been entered by a court or other party?
Yes ______ No ______ If yes, to whom are the payments made?
6. Who will claim this child as a dependent for state/federal income tax purposes?
7. Will you assume all personal obligations related to school requirements for this child that may
include providing for required immunizations, uniforms, fees/fines, citations/ fines for truancy,
attending parent-teacher conferences, attending meetings/hearings concerning discipline, and fulfilling
any special education requirements? Yes ______ No ______
8. Will you assume the responsibility and obligation for making all education decisions?
Yes _____ No ______
I grant the school district permission to investigate the information I have presented in this statement
by discussing the presented information with all appropriate parties, as necessary to confirm the factual
(Signature of Resident)
County of ________________________
State of __________________________
Sworn before me this day of ___________________________________
in the presence of: __________________________________________