Form Pps-F004 - Affidavit Of Residency For Purposes Of Obtaining School Accommodations
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2MILFORD PUBLIC SCHOOLS
MILFORD, CT
PARENT/GUARDIAN AFFIDAVIT #2
AFFIDAVIT OF RESIDENCY FOR PURPOSES OF OBTAINING SCHOOL ACCOMMODATIONS IN THE
MILFORD PUBLIC SCHOOLS
To Be Completed by Parent or Legal Guardian
(use one affidavit per person)
I, ___________________________________, being duly sworn, hereby declare upon pains and penalties of
perjury and false statement that I am the parent/legal guardian of the below-named child(ren), who will be
residing with a legal resident of the City of Milford as follows:
Name: _____________________________________
Address: _____________________________________________________, Milford.
My child(ren) is/are named below as follows:
__________________________________
_______
________
___________________
Name
Age
Grade
School
__________________________________
_______
________
___________________
Name
Age
Grade
School
__________________________________
_______
_________
___________________
Name
Age
Grade
School
By executing this affidavit, I understand that I am representing that my child(ren) is/are entitled to free school
accommodations from the City of Milford by virtue of their having a legal residence at the above-named address.
I hereby represent that my child(ren) are residing at the above-named address:
(1) permanently,
(2) without pay, and
(3) not for the sole purpose of obtaining school accommodations in the Milford Public Schools.
If this changes at any point in time, it is my responsibility to notify the Milford Public Schools regarding the change
in residence and make arrangements for my child(ren) to attend school in their new district of residence. If at any
point in time it is determined that my child(ren) have been receiving free school accommodations in Milford in the
absence of any legal entitlement to same, I understand that the Milford Board of Education reserves the right to
immediately disenroll my child(ren) from the Milford Public Schools, and it will be my responsibility to pay tuition to
the Milford Public Schools for any period of time for which it is determined that the child(ren) were not entitled to
free school accommodations from the City of Milford. Tuition shall be assessed at the current yearly rate. I
understand that if it is determined that I have defrauded the Milford Public Schools, I may also be subjected to the
pains and penalties of perjury and false statement and such other remedies as may be available under law.
I represent that either (PLEASE INDICATE ONE): (a) The person named above has a custodial or legal relationship
with the above-named child(ren) and I have provided the Milford Public Schools with legal documentation of same
such that this person is able to make educational and medical decisions for the child(ren) in my absence; or (b) the
person named above is not the legal guardian or custodian of the child(ren), and cannot be relied upon by the
Milford Public Schools to make educational and/or medical decisions for the child(ren).
Date: 11/01/2006, Revision B
DOC #PPS-F004
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