Residency Affidavit - Imagine Columbus Primary Academy Page 2

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SECTION III (to be completed by the Notary Public):

NOTARY SEAL

STATE OF OHIO, COUNTY OF __________________________

SWORN TO BEFORE ME AND SIGNED THIS___________ DAY OF___________20_____

SIGNED__________________________________________

NOTARY PUBLIC STATE OF OHIO

COMMISSION EXPIRES____________________________

DATE

NOTICE: READ CAREFULLY: Knowingly falsifying this document is a violation of the Ohio Revised Code:

Section 2921.13(A)(6) which is a First Degree Misdemeanor punishable by a prison term of six (6) months

and/or a fine up to $1000.00. Further the affiant will be billed (and prosecuted in court, if necessary) to

collect all back tuition, which may be due. Inaccurate and/or false information will result in immediate

withdrawal of your child(ren) from Columbus City Schools.

This affidavit is valid for the current school year only. You will be required to prove residency again next

school year if you remain in the District.

12/09

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