Sworn Statement By Resident Under 13-1302 printable pdf download

Oley Valley School District

Attachment B - 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 more than one resident adult who will assume responsibility for the

student, all such adult residents must complete and sign this statement.

This is a legal document. You may ask to see a copy of 24 P.S. §13-1302 prior to signing

this document, and consult with an attorney if you have any questions or do not

understand any portion of this document.

1. Your Name _______________________________________________________________

Home Address ___________________________________________________________

Home Telephone Number _________________ Work Number _____________________

2. Do you live in the school district and does the child live with you? Yes _____ No _____

3. Child’s Full Name_________________________________________________________

Birth Date_____________________________ Grade ____________________________

Name & Address of Last School Attended _____________________________________

_______________________________________________________________________

Date child began/will begin to reside in your home ______________________________

4. Are you supporting this child gratis (without personal compensation or gain)?

Yes _____ No _____

5. 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, or attending meetings/hearings concerning

discipline? Yes ____ No ____

6. Do you intend to keep and support the child continuously and not merely through the school

term? Yes ___ No ___

Through my notarized signature, I/We understand that the school district, pursuant to guidelines

issued by the Department of Education and their own written policy, may require other

reasonable information to be submitted to confirm this sworn statement.

Signed by resident(s) and notarized ______________________________________________

12/13/13

Per 24 P.S. §13-1302, a person who knowingly provides false information in the above statement for the

purpose of enrolling a child in a school district for which the child is not eligible commits a summary

offense and shall, upon conviction for such violation, be sentenced to pay a fine of no more than three

hundred dollars ($300) for the benefit of the school district in which the person resides or to perform up to

two hundred forty (240) hours of community service, or both. In addition, the person shall pay all court

costs and shall be liable to the school district for an amount equal to the cost of tuition calculated in

accordance with §2561 during the period of enrollment.

Sworn Statement By Resident Under 13-1302