Sworn Statement By Resident Form printable pdf download

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

accuracy.

______________________________________

(Signature of Resident)

County of ________________________

State of __________________________

Sworn before me this day of ___________________________________

in the presence of: __________________________________________

(Notary)

Sworn Statement By Resident Form