Notarized Residency Affidavit Form - Gwinnett County Public Schools Page 3

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GWINNETT COUNTY PUBLIC SCHOOLS
NOTARIZED RESIDENCY AFFIDAVIT
Non-Parental Affidavit of Residence
DOE Rule 160-5-1-.28
GCPS Procedure JBA
NOTICE OF PENALTIES AND LIABILITY
I understand that:
If I falsify information or defraud the school system on this affidavit, I will be obligated to
pay for the cost incurred by the local school system for the period during which the
ineligible student is enrolled and shall remunerate Gwinnett County Public Schools as set
forth in O.C.G.A. 20-2-133 (a) __________ (Initial)
If the costs incurred by the local school system are collected by an attorney, I will be
obligated to pay for all expenses and attorney’s fees incurred by the Board of Education in
the collection of same__________ (Initial)
I may be prosecuted, held criminally liable and imprisoned for not less than one nor more
than ten years if I am found guilty of forgery in the first degree, pursuant to O.C.G.A. 16-9-
1. __________ (Initial)
I may be prosecuted, held criminally liable, and punished by a fine of not more than $1,000
or by imprisonment for not less than one nor more than five years, or both if I am found
guilty of false swearing pursuant to O.C.G.A. 16-10-71. __________ (Initial)
By initialing on the lines provided next to each of the items listed above, I affirm that I have
read and understand each of these provisions.
I solemnly affirm under the penalties listed above that the contents of this affidavit are true
to the best of my knowledge, information and belief.
_______________________________________________________
Signature of affiant (adult with whom the child/parent is living)
_______________________________________________________
Signature of parent/legal guardian
State of: __________________________________, County of: _________________________
I, ________________________________, a Notary Public for said county and state do
hereby certify that __________________________personally appeared before me this day
and acknowledged the due executing of the foregoing instrument.
Witness my hand and Official Seal, this ___________day of ____________, 2____________
Signature of Notary
Seal
Revised 9/27/13

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