(4) The affidavit shall be in the following form:(i) I, the undersigned, am over eighteen (18) years of age and competent to testify to the facts and matters set forth herein.(ii) ____________________ (name of child), whose date of birth is _____________, is living with me because of the following serious family hardship: (check each that is applicable) _____ death of father/mother/legal guardian
_____ serious illness of father/mother/legal guardian
_____ drug addiction of father/mother/legal guardian
_____ incarceration of father/mother/legal guardian
_____ abandonment by father/mother/legal guardian
_____ assignment of a parent or legal guardian of a child to active military duty
(iii) The name and last known address of the child's parent(s) or legal guardian is: ______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
(iv) My kinship relation to the child is _______________________(v) My address is: ______________________________________________________________________________ |
Street | Apt. No. |
______________________________________________________________________________ |
City | State | Zip Code |
(vi) I assumed informal kinship care of this child for 24 hours a day and 7 days a week on __________________(day/month/year).(vii) The name and address of the last school that the child attended is: ______________________________________________________________________________
______________________________________________________________________________
(viii) The county superintendent may verify the facts contained in the foregoing affidavit and conduct an audit on a case-by-case basis after the child has been enrolled in the county public school system. If the county superintendent discovers fraud or misrepresentation, the child shall be removed from the public school or county public school system roll.(ix) I solemnly affirm under the penalties of perjury that the contents of the foregoing are true to the best of my knowledge, information, and belief. ___________________________________
Signature of affiant
___________________________________
(Day/month/year)
(x) Any person who willfully makes a material misrepresentation in this affidavit shall be subject to a penalty payable to the county for three times the pro rata share of tuition for the time the child fraudulently attends a public school in the county.