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: ________________________