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GrandRapidsFublic Schools

C AFFIDAVITThe purposeof this form is to saffsfythe hgal residency law-Thisform test set up by Michigan is to be completed dnd signedby the bgal parentor guardianwhen he parenUguardian and child are livi,ngwith anotherpersonAfrlD cannotproduceproof of residence^Thb is not a hornelass situation. OF: -* . STATE COUNTY OF:_ ,., _ ) ss. ) )

(Name or Legal Guardian) of Parent

being dulyrwom depcses andmys:

parent of 1. Thathe or sheis a cilstodiat or legalguardlan


whosebirthdateis (Nameof Child) 2. That ttreparentand childllvein fre homeof (Relatlve/Neme of Ptrly) (Address) Thatthe parenFor hgalgtnrdian of the childmnnot producereguircdproofof resldenceprmf of retidencyandverffhs the above Thatthe resldcr{pruvideo required parenUguardian ar.rd familyresideat thisaddress as theirprimaryresidenae.

I desisqF6..i

in thisapplicatigJr.. rn-a{regr_e{ated ___

Fffifica6on

ffiaU@dctrironelng

at dropped ffom scfiooldisficl enrpllment and subjecthe unde[signed to fu3tion charges, eshbhhd schooldistrictrats, for any perlodof tme thatthe child'aesenrolledin the Publh $droolewhilenot a raeidefltFurfrcr,any material falsestatemente penatties pefury. for in this affidavitmaysubiect to crirhlnal the undersigned

to beforeme Subsffibedand surom dayof ....._._.... , 2_ .

Parent/Guadian $ignature
SQnature of Honreomer/Resident
Teleptnnenumberof Homeowner/Resident

Ml Notary Public, KentOowr$,

MyCornrnissbn Expfres: