Arizona Domicile Affidavit Page 3

CERTIFICATION

I, ___________________________________________certify that _________________________________________

(Parent/Guardian)

(Dependent)

is eligible to be claimed as a dependent as defined by the Arizona State Income Tax Code (ARS 43-1001) as of the date of

enrollment for which this application is intended. I further certify that the dependent and I (parent) are currently domiciled in

Arizona and that each of the foregoing statements is a true and correct statement of fact.

___________________________________

Signature of Parent/Guardian*

(seal)

___________________________________

Signature of Notary Public

State of _____________________ County of ___________________

Signed and subscribed before me on this _____________ day of _______________, 20___________

My commission expires: _________________________________

*PROOF OF GUARDIANSHIP MUST BE ATTACHED

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