Independence School District: Residency Affidavit printable pdf download

INDEPENDENCE SCHOOL DISTRICT: RESIDENCY AFFIDAVIT

This affidavit allows students/parents living with another district resident without a lease/rental agreement to register for up to 45 days

with confirmation by the district resident. Within 45 days, the parent must confirm the residency address with one of the following

documents with parent name and current address: (1) recent paystub, (2) insurance bill, (3) bank statement, or (4) federal, state or

court issued documents. Failure to confirm the residency address will result in students being un-enrolled from the ISD.

TO BE COMPLETED BY PARENT/GUARDIAN

I, __________________________________, am residing at ___________________________________________________________,

(Parent’s/Legal Guardian’s Name)

(Address, City, State, Zip Code)

with ________________________________ in the Independence School District. I have been residing there since _______________.

(Resident’s/Homeowner’s Name)

(Date)

My previous address was ______________________________________. I attest that I have no other residence.

(Address)

The children for whom I am applying for admission to the Independence School District are as follows:

Child’s Name

Date of Birth

Grade

School Enrolling

TO BE COMPLETED BY RESIDENT/HOMEOWNER

I, _______________________________________, am residing at ______________________________________________________,

(Resident’s/Homeowner’s Name)

(Address)

in the Independence School District. My phone number is _________________________. I hereby attest that the above listed

Parent/Legal Guardian and his/her children have been residing with me at the above address since ______________________ (Date).

LEGAL DISCLAIMER

I understand that the information that I am living at the above address will be forwarded to appropriate investigative authorities.

I have provided accurate and truthful information to the best of my knowledge. I have not knowingly withheld, concealed, or

misrepresented any information that would have a material bearing upon the eligibility of the above child(ren) to attend the

Independence School District.

Further, I understand that persons making a false affidavit or providing false proof of residency documentation may be subject to

prosecution. Violators may be charged with a misdemeanor and, upon conviction, may be jailed and/or fined. I am aware that the

district may vigorously investigate and prosecute violations. I acknowledge that, if investigation reveals that I did not provide true

information, the above child(ren) will be withdrawn from the Independence School District, and I may be obligated to pay any tuition

monies then due.

I am at least eighteen (18) years of age and I state that all statements made herein are made under oath and are true and correct

based upon my personal knowledge and belief.

Note: If both signatures cannot be notarized at the same time, two separate forms can be submitted.

__________________________

____________

__________________________

____________

Signature of Parent/Legal Guardian

Date

Signature of Resident/Homeowner

Date

NOTARY ACKNOWLEDGEMENT CERTIFICATE (must be completed by a certified notary public)

STATE OF MISSOURI

)

ss.

COUNTY OF ______________

)

On the ________ day of ______________________, 20______, appeared _____________________________________________,

to me personally known and did say that he/she has read the foregoing and states that it is true and correct according to his/her best

information and belief.

My Commission Expires:

_____________________________________________________

Notary Public

Independence School District: Residency Affidavit

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