Statement Of Residence - Houston Independent School District printable pdf download

Statement Of Residence - Houston Independent School District

STATEMENT OF RESIDENCE

STATE OF TEXAS

]

COUNTY OF HARRIS

]

BEFORE ME, the undersigned authority, on this day personally appeared

______________________________________________________ , who on his/her word says:

My name is ___________________________________________________ and I live at

__________________________________ Apt. # ________ in Houston, Texas, 77 ________ .

This is the legal residence of ____________________________________________________

who is my __________________________ .

Because of circumstances beyond my control, my child(ren) and I must reside at this address.

I agree to provide to the principal of _________________________________________ School,

and the Attendance Boundaries and Transfer Department, notification of change of address

when such occurs.

I further agree to withdraw _____________________________________________________

from the school in the event the above statement is found to be incorrect.

CERTIFICATION

I hereby certify that the information stated herein is true and accurate to the best of my knowledge.

I am not making this request for the purpose of obtaining some benefit or admission into a school

or program of the Houston Independent School District. I understand that submitting this form with

false information may constitute a violation of Section 37.10 of the Texas Penal Code.

Signed this the ______________ day of ___________________, 20______

______________________________________

___________________________________

Signature

Please Print Name

______________________________________

___________________________________

Campus Employee's Signature

Title

02-106 Statement of Residence

HISD Graphics —4/02

AP - 63

Statement Of Residence - Houston Independent School District