Form R101 - Residency Verification Affidavit Form - Worthington School District - Ohio
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1
2VERIFICATION OF RESIDENCY AFFIDAVIT
(Form R101 blue)
Today’s Date
WORTHINGTON SCHOOL DISTRICT
____/____/____
TO BE COMPLETED BY PARENT OR GUARDIAN - PLEASE PRINT/TYPE ALL INFORMATION EXCEPT SIGNATURE
FORMER ADDRESS
NEW ADDRESS
Street
Street
________________________________________________
________________________________________________
City
State
Zip Code
City
State
Zip Code
________________________________________________
________________________________________________
Phone Number
Phone Number
Name of person(s) with whom you are residing or from whom you are renting:_____________________________________
Your relationship to that person: ________________________________________________________________________
NAME OF STUDENT - PLEASE PRINT
Name of Student
Birthdate
Worthington School/Grade
Former School
1)
2)
3)
Parent(s) Guardian Name:______________________________________________________________
Where are you employed?____________________________________ Phone ____________________
* In the case of a divorce or dissolution, documentation of custody signed by a judge must
accompany this form
AFFIDAVIT BY PARENT
I, ____________________________________________, being first duly cautioned, do solemnly swear or affirm the following:
I am the parent, guardian or legal custodian of __________________________________ and I reside at _________________________
____________________________________________. This has been my place of residence since _____________________________.
I acknowledge and understand that if the above information is not true and correct, that knowingly swearing or affirming the truth thereof
constitutes criminal falsification. A violation of Ohio Revised Code Section 2921.13, a first degree misdemeanor, punishable by a
maximum fine of $1,000 and/or a maximum term of imprisonment of six months. Further, if the student is found to not be a legal
resident, the district will seek remuneration of each day the student illegally attended school in the district.
I agree that The Worthington School District, if they deem necessary, has the right to investigate my residency. I agree to allow the
release of rental information and also, utility customer information to a representative of The Worthington School District.
____________________________________________________________________________
Parent/Guardian Signature
____________________________________________________________________________
Please PRINT name signed above
SWORN TO AND ASCRIBED IN MY PRESENCE THIS ____DAY OF ______________________________ 20____
Notary Public
Seal
Address
or
City
State
Stamp
Phone
Zip Code
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