Residency Affidavit Form - Round Lake School District

RESIDENCY AFFIDAVIT FORM

This form must be completed for ALL enrolling students whose parent/guardian is unable to provide proof of residency

in their name because they are renting a residence without a formal contract or they are living with someone and all proof

of residency documents are in that person’s name

The Residency Affidavit Form is needed to determine the student’s district of residence which is crucial to accurately calculate general education

revenue, other state aids, levy authority, and in many cases, determine responsibilities for tuition.

SECTIONS 1 & 2 ARE TO BE COMPLETED BY THE PARENT/GUARDIAN

SECTION 1: PARENT/GUARDIAN INFORMATION

PARENT/GUARDIAN NAME:

RELATIONSHIP:

(LEGAL)

LAST

FIRST

MIDDLE INITIAL

(TO STUDENT)

I attest that I do not own or rent/lease any other permanent home or residency inside of Round Lake Area Schools. I understand that any false or misrepresented

information will necessitate further action by Round Lake Area Schools District # 116.

WARNING:

A person is guilty of a class C misdemeanor if (a), that person knowingly enrolls or attempts to enroll in the schools of a school district on tuition free basis a pupil know by

that person to be a nonresident of the district, or (b), that person knowingly or willfully presents to any school district any false information regarding the residency of a pupil for

the purpose of enabling the pupil to attend any school in that district without the payment of a nonresident tuition charge.

SIGNATURE:

DATE:

MONTH/DAY/YEAR

SECTION 2: STUDENT INFORMATION

The following students reside with the parent/guardian identified in SECTION 1.

STUDENT #1 NAME:

BIRTH DATE:

(LEGAL) LAST

FIRST

MIDDLEINITIAL

MONTH/DAY/YEAR

STUDENT #2 NAME:

BIRTH DATE:

(LEGAL) LAST

FIRST

MIDDLEINITIAL

MONTH/DAY/YEAR

STUDENT #3 NAME:

BIRTH DATE:

(LEGAL) LAST

FIRST

MIDDLEINITIAL

MONTH/DAY/YEAR

STUDENT #3 NAME:

BIRTH DATE:

(LEGAL) LAST

FIRST

MIDDLEINITIAL

MONTH/DAY/YEAR

SECTION 3: PROPERTY OWNER / LANDLORD INFORMATION

Please submit 2 of the following proofs of

PROPERTY OWNER / LANDLORD NAME:

address for returning students

(LEGAL) LAST

FIRST

MIDDLE INITIAL

New to district require 3 proofs

I currently own/rent/lease a residence located at the following address:

Category i- one document required

ADDRESS:

APT #:

Recent tax bill and proof of payment

BLDG/HOUSE NUMBER / STREET NAME / STREET TYPE (ST., AVE., ETC.) / STREET DIRECTION (N, S, NE, ETC.)

Mortgage papers

CITY:

STATE:

ZIP:

Signed and dated lease and proof of last

month’s payment

Please check one of the following responses:

Category ii- two documents required

I currently rent/lease the residence above to the person identified in SECTION 1.

o

Driver’s license

I currently allow the person identified in SECTION 1 to occupy the residence listed above.

o

I certify that the information contained in SECTION 1 is true and correct to the best of my knowledge and belief.

o

Illinois State ID

Vehicle registration (current year)

SIGNATURE:

DATE:

Voter registration

MONTH/DAY/YEAR

Mexican/ Matriculate Consular ID card

Current public aid card (within 60 days)

NOTARY SEAL

Current homeowner’s/renters’ insurance

policy and premium payment receipt

(within 60 days)

Current phone, gas, cable, electric and/or

water bill (within 60 daysj

FOR NOTARY USE ONLY

STATE OF: _________________________________

COUNTY OF: ________________________________

SIGNED BEFORE ME:_________________________

SIGNATURE: ________________________________

NOTE: AFFIDAVIT MUST BE ACCOMPANIED BY 2 CURRENT PROOFS OF ADDRESS FROM THE OWNER OF THE PROPERTY AND MUST

BE NOTRIZED. SEE REQUIERED DOCUMENTS.

AFFIDAVITS ARE VALID FOR 1 YEAR

05-12