Educational Residency Affidavit
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1
2NOTE:
If this Affidavit is used, an Affidavit C must also be completed by the
AFFIDAVIT B
Caregiver Adult
STATE OF NORTH CAROLINA )
COUNTY OF HENDERSON
)
Please Print or Type
IN THE MATTER OF
Full Name of Student
EDUCATIONAL RESIDENCY AFFIDAVIT
Address of Parent, Guardian or Legal Custodian
(PARENT, GUARDIAN OR
LEGAL CUSTODIAN)
City
State
Zip
Current Grade
Last School Attended
(G.S. 115C-366(a3))
Printed Name of Parent, Guardian or Legal Custodian
Sex
Date of Birth
Age
The undersigned, being first duly sworn, says:
1.
I am the parent, guardian or legal custodian (circle one) of the child referenced above.
2.
My child resides or will be residing with the adult (hereinafter caregiver adult) listed below and the
caregiver adult is domiciled at the address listed below:
Name of Caregiver Adult
Address
3.
My child resides with the above-referenced caregiver adult for the following reason(s)
(check all that are true and provide all supporting documentation):
a.
The death, serious illness, or incarceration of a parent or legal guardian; or
b.
The abandonment by a parent or legal guardian of the complete control of the student as
evidenced by the failure to provide substantial financial support and parental guidance; or
c.
Abuse or neglect by a parent or legal guardian (under G.S. 115C-366(h)(1), a child is
considered “abused or neglected if there has been an adjudication of that issue”) (attach
adjudication or court order); or
d.
The physical or mental condition of the parent or legal guardian is such that he or she cannot
provide adequate care and supervision of the student. Please describe the physical or mental
condition of the parent or legal guardian_________________________________________
_______________________________________________________________________; or
e.
The relinquishment of physical custody and control of the student by the student's parent or
legal guardian upon the recommendation of the Department of Social Services or the
Division of Mental Health (attach written recommendation); or
f.
The loss or uninhabitability of the student's home as the result of a natural disaster.
R&S 534641-1
Henderson County Public Schools 8.5.09dlj
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