Residency Affidavit
STATE OF NEW JERSEY
COUNTY OF BERGEN
ss:
I,
being duly sworn, deposes and states I am the owner or corporate
officer of the owner's property located at
in the Borough of Lodi, NJ.
The names of permissible tenants are as follows:
a.
_
d.
_
b.
e.
c.
f.
How long will the above persons be living in your home?
What circumstances brought them to reside with you?
I am making)his affidavit knowing that the Lodi Board of Education will rely on same in determining whether
the student(s) listed below will be considered a pupil who is entitled to an education free of charge.
a. d.
b.
e.
c.
f.
Under PENALTY OF PERJURY and subject to the laws of this state,
I
declare that the information
provided herein is true and correct and of my own personal knowledge and that, if called upon to testify,
I
would be competent to do so.
I
understand that the statements in this application are subject to verification
by the Lodi Board of Education and false statements could subject me to tuition and transportation charges.
(see attachment)
I
also understand that it is my responsibility to immediately notify the school of any
changes of circumstances affecting the information set forth herein.
(Landlord)
On this, the
day of
20
,
before me a notary public, the undersigned officer,
personally appeared
, known to me (or satisfactorily proven) to be the person whose name is
subscribed to the
within instrument, and acknowledged that he executed the same for the purposes therein
contained. In witness hereof. I
hereunto set my hand and official seal.
Notary Public
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