5150-E.5 School Admissions Exhibit Affidavit of Residency

Affidavit of Residency – Landlord
This form may be submitted sworn or unsworn

 

Instructions

Please complete this form, sign it 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. Check all that apply in the boxes below.

Please answer all questions.

STATE OF NEW YORK )

ss:

COUNTY OF SUFFOLK )

I, ______________________________________________________ ,

□ am the recorded owner (or authorized master tenant/leaseholder) of the property:____________________

□ am duly designated agent for the owner of the property:_______________________________________

□ am a relative, family member, or family friend renting my home

at:_________________________________________________________________________________

______________________ which is located within the territorial boundaries of the Brentwood

School District.

This rental/living arrangement began on_________________ and will end on_______________________ .

□ There is a written lease for the premises.

I am renting/providing a room/apartment to the following persons

Parent/Guardian
Parent/Guardian
Child(ren) Seeking to Enroll

The terms and conditions of the tenancy/occupancy are as follows (Specify monthly rent, space occupied) ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

5150-E.5

SCHOOL ADMISSIONS EXHIBIT

Affidavit of Legal Residence – Owner
This form may be submitted sworn or unsworn

□ This statement is submitted unsworn
or
□ This statement is sworn to under the penalties of perjury. The above information made by me is true, and I understand that if the statements I have made are false, the Brentwood Union Free School District will take legal action to collect tuition charges if the student/s is/are illegally registered. Any person or persons, in addition to the parents or guardians, who provide false evidence of residency, will be prosecuted. The above information made by me is true, and I know that perjury is a Class A misdemeanor pursuant to section 210.45 of the penal code.

________________________________ ________________

Signature Date

 

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

 

 

R E C E I P T

DATE: I HAVE RECEIVED $ FOR RENT FROM (Tenant) FOR HOUSING AT (Address) Homeowners Signature Notary Date Date

5150-E.5

SCHOOL ADMISSIONS EXHIBIT

Affidavit of Legal Residence – Owner
This form may be submitted sworn or unsworn

Download the School Admissions Exhibit Affidavit of Residency PDF