Atlantic City Public Schools 1300 Atlantic Avenue Atlantic City, NJ

Atlantic City Public Schools

1300 Atlantic Avenue

Atlantic City, NJ 08401

Phone: (609) 343-7200 Fax: (609) 343-1415

Residency Affidavit

Resident Providing Housing for Another Family

State of New Jersey )

) ss:

County of Atlantic )

I, _______________________________, of full age, being duly sworn

according to law, on my oath depose and say:

1. I am domiciled and reside at____________________________________

in the City of Atlantic City, County of Atlantic and State of New

Jersey. This has been my place of domicile and residence since

_______________________.

2. I own/rent (circle one) the premises identified above. If the

premises are rented, I have attached an original or certified copy of

the lease or a sworn statement from the landlord (if there is no

lease) (“Residency Affidavit 1”), together with four (4) additional

forms of proof showing residence within the Atlantic City Public

School District (hereinafter referred to as “the District”). If the

premises are owned, I have attached an original or certified copy of

the deed or contract of sale, together with four (4) additional forms

of proof showing residence within the District.

Atlantic City Public Schools

1300 Atlantic Avenue

Atlantic City, NJ 08401

Phone: (609) 343-7200 Fax: (609) 343-1415

3. I hereby certify and declare, under penalty of law, that the

following persons are in full-time residence in our home as an entire

family, at no cost, for the period of_____________________

through__________________________. (This Affidavit is valid only

through the current school year.)

Name

Relationship

(Grade if Applicable)

Name

Relationship

(Grade if Applicable)

Name

Relationship

(Grade if Applicable)

Name

Relationship

(Grade if Applicable)

4. __________________________________________________ (hereinafter

referred to as the “parent(s)”) and his/her/their child/children

(hereinafter referred to as the “child/children”) are residing

temporarily with me in my home.

5. The parent(s) shall retain all personal obligations of the

child/children relative to school requirements and shall ensure that

the child/children complies with all of the policies, rules and

regulations of the District and the laws of the State of New Jersey.

6. I am aware that I have the obligation to notify the Atlantic City

Board of Education (hereinafter referred to as “the Board”)

immediately if any of the above circumstances change.

7. This Affidavit is made in compliance with the provisions of N.J.S.A.

18A:38-1 and is submitted for the purpose of inducing the Board to

accept the child as a student in the District on a tuition-free

basis. I state that the information contained in this Affidavit is

true and accurate and acknowledge the Board’s reliance upon the

truthfulness and accuracy of this information.

Atlantic City Public Schools

1300 Atlantic Avenue

Atlantic City, NJ 08401

Phone: (609) 343-7200 Fax: (609) 343-1415

I am aware that if any of the statements contained in this Affidavit

are willfully false, I am subject to the criminal penalties provided

by law for perjury and/or false swearing, and I will be personally

liable for the payment of tuition for the child retroactive for the

period of ineligible attendance of said child in the District’s

schools as well as any related costs and/or fees, including

attorney’s fees, incurred as a result of such ineligible attendance.

Signature(s) of Owner(s)/Renter(s)

_________________________________

Telephone Number

Signature(s) of Non- Resident

Parent(s)

____________________________________

Telephone Number

Sworn and subscribed to before me

This__ day of______, 20____

_______________________________

Notary Public

My Commission Expires: __________