School Admissions Exhibit - Affidavit Of Residency printable pdf download

School Admissions Exhibit - Affidavit Of Residency

BRENTWOOD UNION FREE SCHOOL DISTRICT

5150-E.5

SCHOOL ADMISSIONS EXHIBIT

Affidavit of Residency

Please note a copy of a photo ID is required with this form.

STATE OF NEW YORK

} ss:

COUNTY OF

)

I hereby certify that I reside at ______________________________________________ ,

(List Full Address)

which is within the boundaries of the Brentwood School District; that as the parent or

legal guardian, I am seeking to have the following student (s) registered in the Brentwood

School District:

Full Names (s)

Age

I hereby certify that this residence is the subject student’s actual and only residence, and

that I have complete custody and control over such student (s). I recognize that the

Brentwood School District will rely upon this representation with respect to domicile and

I agree to bear legal responsibility for any inaccuracy of such representations.

_______________________________________

_______________________

Signature

Date

Sworn to before me this ___________ day of __________________, 20____

______________________________

Notary Public

Note: This is an affidavit which sets forth facts, the truth of which are sworn under oath.

False swearing may constitute a crime punishable as provided in the Penal Law of the

State of New York. The Brentwood School District may also take legal action to collect

tuition charges in any case where a student is illegally registered.

(FOR SCHOOL USE ONLY)

Reviewed and approved by: ________________________________________

Coordinator of Attendance

________________

Date

Approved by the Board of Education:

1/21/10

School Admissions Exhibit - Affidavit Of Residency