Third-Party Affidavit
- -.
---------------------------
-
--
-------
CITY SCHOOL DISTRICT OF NEW ROCHELLE 515 NORTH AVENUE NEW ROCHELLE, NEW YORK, 10801 THIRD·PARTY AFFIDAVIT AFFIDAVIT BY THIRD·PARTY TO CONFIRM RESIDENCY Instructions Please complete this form, sign it, have your signature notarized, and return it to the District's Office of Pupil Services, 515 North Avenue, Third Floor, New Rochelle, New York 10801. 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 answer all questions. IN THE MATTER OF THE RESIDENCY OF:
Student's name
STATE OF NEW YORK }: ss.: COUNTY OF WESTCHESTER The undersigned, being duly sworn, deposes and says, under penalties of perjury, as follows: 1. My name is: 2. My home address and telephone number are: 3. I am submitting this affidavit to establish the residency of the following Student:
Student name
4. My relationship to the Student's and the Student's family is:
5. The name(s) of the Student's Parent(s)/Guardian(s)/Custodian(s) is/are:
Revised January. 2017
Third Party Affidavit Page 2
6. The Student lives at the following address:
__
7 ._T_h-=--e --=-S_:c:.tu-=--dec:...;_n_:_t _ha:...cs_.:.li-=--vec:...;_ac_:_:t__::th_:_::e_::a_:_b-=--ov:....::e_:a.:..::.d..:::..:dr--=-es.:_:s_::s_:_in:_:_ce::_ (if known) 8. The names of the people in parental/guardian are:
relationship to the Student living with the Student Relationship to Student
9. The basis for my statements in Paragraphs 5, 6, 7 and 8 above is: Please explain how it is that you know the information reported above
10. I understand that the City School District of New Rochelle 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
Printed name
Sworn to before me this Day of _______
, 201
Notary Public
Revised January. 2017
---------------------------
-
--
-------
CITY SCHOOL DISTRICT OF NEW ROCHELLE 515 NORTH AVENUE NEW ROCHELLE, NEW YORK, 10801 THIRD·PARTY AFFIDAVIT AFFIDAVIT BY THIRD·PARTY TO CONFIRM RESIDENCY Instructions Please complete this form, sign it, have your signature notarized, and return it to the District's Office of Pupil Services, 515 North Avenue, Third Floor, New Rochelle, New York 10801. 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 answer all questions. IN THE MATTER OF THE RESIDENCY OF:
Student's name
STATE OF NEW YORK }: ss.: COUNTY OF WESTCHESTER The undersigned, being duly sworn, deposes and says, under penalties of perjury, as follows: 1. My name is: 2. My home address and telephone number are: 3. I am submitting this affidavit to establish the residency of the following Student:
Student name
4. My relationship to the Student's and the Student's family is:
5. The name(s) of the Student's Parent(s)/Guardian(s)/Custodian(s) is/are:
Revised January. 2017
Third Party Affidavit Page 2
6. The Student lives at the following address:
__
7 ._T_h-=--e --=-S_:c:.tu-=--dec:...;_n_:_t _ha:...cs_.:.li-=--vec:...;_ac_:_:t__::th_:_::e_::a_:_b-=--ov:....::e_:a.:..::.d..:::..:dr--=-es.:_:s_::s_:_in:_:_ce::_ (if known) 8. The names of the people in parental/guardian are:
relationship to the Student living with the Student Relationship to Student
9. The basis for my statements in Paragraphs 5, 6, 7 and 8 above is: Please explain how it is that you know the information reported above
10. I understand that the City School District of New Rochelle 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
Printed name
Sworn to before me this Day of _______
, 201
Notary Public
Revised January. 2017
