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Form R101 - Residency Verification Affidavit Form - Worthington School District - Ohio Page 2

WORTHINGTON SCHOOL DISTRICT

200 E. WILSON BRIDGE RD.

WORTHINGTON, OH 43085

(614) 450-6000

AFFIDAVIT- Sharing Residences

STATE OF OHIO

FRANKLIN COUNTY, S.S.

I, _____________________________, being first duly cautioned, do solemnly swear or affirm the

following:

1. I am the owner or renter of the residence at ____________________________________________,

Street Address

___________________________, Ohio ___________, located in the Worthington School District.

City

Zip Code

2. The following individual(s) _________________________________________________________

Name of Parent/Guardian(s)

________________________________________________________________________________

Name of Student(s)

is/are living at my above stated residence and have so since the _____ day of____________,

__________.

3. 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. Furthermore, by signing this form I am accepting

financial responsibility for tuition for the above named student(s) should the student reside

elsewhere. The current tuition rate is $1,067.19 per month per student.

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/or utility customer information to a

representative of The Worthington School District.

Signature of Resident of Property: _________________________________

Sworn to or affirmed and subscribed before me this _____day of _____________, __________, by

__________________________________________.

____________________________________________________

Notary Public

Form R101 - Residency Verification Affidavit Form - Worthington School District - Ohio Page 2