5112 Form #1

DECLARATION OF LEGAL RESIDENCY
Family Members Living with Relatives or Family Friends

To be completed by property owner

Property Owner: ________________________________________________________________
                                               Name of Property Owner - Please print

If the living arrangement of the student should change from what is stated on this form, it is the responsibility of the property owner to notify the Office of the Superintendent within five (5) business days in writing.

____________________________________________________________
       Signature of Property Owner - Sign in the Presence of Notary Public

Property Address: _______________________________________________________________

Phone Number: ___________________________________ Email: _______________________

The Property Owner must accompany the parents to the meeting with the Superintendent of Schools to present this document.

Children and Family Member living with Property Owner

Adult #1 __________________________________     Adult # 2 ___________________________
Child #1 __________________________________     Child # 2 ___________________________
Child #3 __________________________________     Child # 4 ___________________________

I am making the above statements as a true and bona fide representations, I fully understand that if I make a statement that is false and which is intended to mislead a public servant in the performance of his/her function, I will be in violation of Section 53-157b of the Connecticut General Statutes.  The section of the law refers to making a fraudulent statement is a Class A misdemeanor and is punishable by a fine, not to exceed $1,000 and/or up to one year of incarceration.

I further understand that I may be required to update this information at any time and agree to do so upon request from the ___________ Board of Education.  I may be made to pay for services received if such services were delivered under fraudulent statements and/or circumstances.

NOTARIZED SECTION

On this date __________________ _______________________ appeared before me personally
                       Month/Day/Year       Print Name of Property Owner

To be known as the individual described herein, and who executed this foregoing document, and he/she duly acknowledged to me under oath to the truth of his/her statement, before me.

_________________________________       _____________________________                                      SEAL
Signature of Notary Public                                  Commission Expiration Date

This form is to be completed by the custodial parent, guardian and student (where applicable). Once the forms are completed and notarized, a meeting with the Superintendent should be schedules. Call _____________________.

PLEASE FILL IN ALL BLANKS

School: ___________________________  Grade: _____________________

Student's Name: _______________________________________________ Address: ________________________

Home telephone number: _____________________ Name under which number is listed: _____________________

Name of student's father: _______________________ Father's address: __________________________________
                                                                                                                                     Street, town, zip

Name of student's mother: ______________________ Mother's address: __________________________________
                                                                                                                                     Street, town, zip

Please answer the following questions:

•  Is remuneration to be received for housing the student, i.e., room, board, travel, medical?   [  ]  Yes     (please specify)  [  ]  No

•  List major reasons for the child residing in ____________________ :

___________________________________________________________________________________________

•  Name of person(s) having direct and primary responsibility/authority of the student's daily affairs:

___________________________________________________________________________________________

•  Name of person(s) authorized to act in child's behalf concerning any medical, disciplinary, or administrative matters: ________________-

Signature (Parent/Legal Guardian) ____________________________________________ Date : ____________________

I hereby declare under the penalties of perjury that all of the information supplied on this form is correct to the best of my knowledge.  I understand that if any of the information is incorrect, and the student is not entitled to enroll tuition-free as a _______________ resident, the student shall be discharged from enrollment in the _____________ Public Schools according to the Connecticut General Statutes, Section 10-186, and 10-253, and the prevailing tuition charge for such student will be assessed against me and/or us for each day the student was so enrolled.

NOTARIZED SECTION

On this date ____________________ ____________________________ appeared before me personally
                          Month/Day/Year             Print Name of Property Owner

To be known as the individual described herein, and who executed this foregoing document, and he/she duly acknowledged to me under oath to the truth of his/her statement, before me.

_________________________________     _____________________________                    SEAL
Signature of Notary Public                                    Commission Expiration Date

Once this document is completed and notarized, a meeting with the superintendent must be scheduled before enrollment is completed.

Superintendent's Approval: __________________________________________  Date: ________________________