Notarized Residency Affidavit Form - Gwinnett County Public Schools (Page 2 of 3) in pdf

Notarized Residency Affidavit Form - Gwinnett County Public Schools Page 2

GWINNETT COUNTY PUBLIC SCHOOLS

NOTARIZED RESIDENCY AFFIDAVIT

Non-Parental Affidavit of Residence

DOE Rule 160-5-1-.28

GCPS Procedure JBA

2. The name and last known address of the child’s parent(s) or legal guardian:

Name:

Address:

City:

State:

Zip Code:

3. This student began 24 hours per day and seven days per week residency in my home on

_____/_____/_____

(day/month/year)

4. The name and address of the last school that the student attended is:

Name of School:

Address:

City:

State:

Zip Code:

5. The Superintendent of Gwinnett County Public Schools or his or her designee may

verify the facts contained in this affidavit and conduct an audit on a case-by-case basis

after the child has been enrolled in the county public school system. The audit may also

include a personal visit by a school district attendance officer or other employee of the

district at the residence provided in this affidavit to verify the facts sworn to in this

affidavit. If the superintendent discovers fraud or misrepresentation, the child shall be

withdrawn from school.

Assurances:

1. I attest that this request to attend _________________________________School

is not primarily related to attendance at a particular school, nor is this affidavit

being completed for the purpose of participating in athletics at a particular

school, taking advantage of special services or programs offered at a particular

school, or any other similar reason.

2. I further attest that the student named above is not now under a long-term

suspension or expulsion from his/her most recent school nor is currently subject

to a recommendation for long-term suspension or expulsion from his/her most

recent school.

3. I understand that if any of the information provided on this affidavit is changed

for any reason, it is my responsibility to immediately notify the school system.

Revised 9/27/13

Notarized Residency Affidavit Form - Gwinnett County Public Schools Page 2