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5150-E.1 School Admissions Exhibit Admissions of Resident Student

  • 5000: Student Policies
5150-E.1 School Admissions Exhibit Admissions of Resident Student

Third Party Affidavit Attesting to Physical Presence

 

 

Instructions

Please complete this form, sign it, have your signature notarized, and return it to the District’s Central Administration Office. 

This is a legal document. Any person giving false information may be subject to prosecution for the crimes of perjury and/or offering a false instrument.

 

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

Please answer all questions.

STATE OF NEW YORK } ss:

COUNTY OF )

The undersigned, being duly sworn, deposes and says, under penalties of perjury, as follows:

  1. My name is: ______________________________________________________.
  1. My home address and telephone number are: ____________________________

_________________________________________________________________

  1. I am submitting this affidavit to establish the residency of the following Student:

_________________________________________________________________

Student name

  1. My relationship to the Student’s and the Student’s family is: ________________

_________________________________________________________________

 

  1. The name(s) of the Student’s Parent(s)/Guardian(s)/Custodian(s) is/are:

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

  1. The Student lives and is physically present at the following address:

_________________________________________________________________

_________________________________________________________________

  1. The Student has lived at the above address since __________________________ (if known).
  1. The names of the people in parental/guardian relationship to the Student living with the Student are:

 

____________________________ _____________________________

____________________________ _____________________________

____________________________ _____________________________

 

____________________________ _____________________________

  1. My statement is based upon the following: (Indicate basis of knowledge of physical presence)

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

  1. I understand that perjury is a Class A misdemeanor pursuant to section 210.45 of the penal code. Any person or persons, in addition to the parents or guardians, who provide false evidence of residency, may be prosecuted.
  1. I also understand that the Brentwood Union Free School District will rely upon the truthfulness of the statements made in this document in deciding whether or not to enroll the student in the public schools of the School District.

__________________________ ______________________

Signature Date

Sworn before me this______________________

day of__________, 20___

___________________

Notary Public

Approved by the Board of Education: 01/21/10

Revision approved by the Board of Education: 08/17/17

Revision approved by the Board of Education: 12/17/20

Revision approved by the Board of Education: 09/26/24

Download the School Admissions Exhibit Admissions of Resident Student PDF