5150-E.4 School Admissions Exhibit Parent Affidavit of Emancipation

Affidavit of Residency

Instructions

Please complete this form, sign it, have your signature notarized, and return it to the District’s Central Administration Office. Proof of your own residency in the Brentwood Union Free School District must be submitted with this affidavit. 

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. In addition, if you enroll a child knowing that s/he does not meet the legal standards for enrollment, you may be liable for the payment of tuition costs for the student. The information provided by you will be used by Brentwood Union Free School District to determine whether a child is entitled to a free public education in the District’s Schools.

If you have a court order granting you custody or legal guardianship, you do not need to complete this form. Instead, bring a copy of the court order to the District’s Central Administration Office.

Please answer all questions.

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

STATE OF NEW YORK } ss:

COUNTY OF ________________________ )

I, ______________________________________ being duly sworn, deposes and states that I reside at

(List Full Address)

which is within the boundaries of the Brentwood School District; that as the parent or legal guardian, I am seeking to register the following student (s) in the Brentwood School District:

Full Names (s) Date of Birth Age

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I hereby certify that this residence is the student(s)’s actual only residence, and that I have and complete care, custody, and control over such student (s). I understand that the Brentwood School District will rely upon the truthfulness of my statements made in this affidavit in determining whether or not to enroll the above-named children in the public schools of the School District at public expense.

The above information made by me is true. I understand that if it is determined, because of untruthful statements on my part, that the child is not a resident of the School District, I may be liable for tuition charges at the rate permitted by law for the child’s attendance during any period(s) of non-residency.

I understand that it is my responsibility to notify the Brentwood School District when I move and no longer reside in the District.

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.

This affidavit is sworn to under penalties of perjury.

Signature Date

Sworn to 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 Parent Affidavit of Emancipation PDF