SCHOOL BOARD OF BROWARD COUNTY, FLORIDASTATEMENT OF PROVISIONARY DOMICILE

In accordance with School Board Policy 5.1, a student shall attend the school in the boundary in which the parent(s) or legal guardian(s) reside. It is the responsibility of the parent(s) or legal guardian(s) to provide proper documentation to verify their residence.When a family is “in transition” and resides with another person or person(s)due to loss of housing, economic hardship, or a similar reason; is living in motels, hotels, travel trailer parks, or camping grounds due to the lack of alternative adequate accommodations; is living in emergency or transitional shelters; is abandoned in hospitals; or is awaiting foster care placement (F.S. 1003.01 (12) a.); then this family is considered a family in transition and is eligible for services under the McKinney Vento Homeless Education Act. The Provisional Domicile form is not applicable to this population.

A family may claim Provisional Domicile when the family is unable to verify permanent residence, for reasons other than those addressed under the McKinney Vento Homeless Education Act. Provisional Domicile is subject to approval by the school principal and shall be renewed every 30 calendar days. In rare circumstances, when provisional domicile represents a permanent residence, the principal may determine that the family may renew this form at the start of each school year.

I certify that the above information is true and correct. I understand that this information will be verified and if found to be fraudulent, my child(ren) will be immediately withdrawn and assigned to his/her proper boundaried school and that falsifying my residence when enrolling my child(ren) may result in a report to law enforcement for prosecution.

Documentation Provided:

_____ Hotel bill Notes:_____ Letter from employer_____ Repair contract_____ Other

Date Submitted and Approved:____________________________

Date for Re-evaluation:_____________________________________

Florida Statute §837.06 provides that whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his official duty shall be guilty of a misdemeanor of the second degree. Additionally, a person who knowingly makes a false declaration under penalties of perjury is guilty of the crime of perjury by false written declaration, a felony of the third degree.

I am unable to provide documentation of my permanent residence at this time because:

(name of parent)

(city, state, zip)

(Signature of Parent/Guardian)

(print, type or stamp name of notary)

(Signature of Principal)

(date)

(date)

(street address)

I agree to immediately, within 10 days, notify the School District, in writing, of any future changes in address or living arrangements of this (these) child(ren). Under penalty of perjury, I hereby declare that I have read this document and the above facts are true and correct.

Newly arrived in area, living in temporary housing (i.e. hotel, with family, with friends, etc.). I understand this form must be renewed every 30 calendar days.

Job transfer, staying in temporary housing, or house being renovated and staying in temporary housing. I understand this form must be renewed every 30 calendar days.

Other, to be approved by the principal for up to one school year; new form must be completed each year.

Acknowledgement

(Notary Seal)

TO BE COMPLETED BY THE PARENT OR LEGAL GUARDIAN:

I, ______________________________________________________, reside at______________________________________________________________________________________________

______________________________________________________, with my child/children_______________________________________________________________________________

on a full-time basis (7 days a week)

Form # 0314Q rev 4/19/2013