Shared Residency Affidavit

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Registration Services 25 Churchill Avenue Palo Alto, CA 94306

Tel. 650-329-3707 Updated 12/18/2017

This shared residency affidavit must be completed if a student and their parents/guardians are BOTH living fulltime in the home of an individual living within the attendance boundaries of the Palo Alto Unified School District (PAUSD). The proper completion of this affidavit may allow a student in a shared residency to attend school in PAUSD (Ed Code 48204).

Shared Residency Requires: 1) The student and student’s parents/guardians live at the address listed fulltime. Any change of address will revoke this permit, and parent/guardian

must notify PAUSD Registration Services of such change within 30 days.2) This affidavit must be signed in the presence of a notary, and notarized, annually.

The RESIDENT of the home must provide (1) Government Issued Photo Id (state Driver’s License, state ID card, passport) AND (2) three (3) forms of evidence of ownership/rental: (a) one of the following: current property tax bill OR current lease/rental agreement; (b) two of any of the following: utility, internet, cable, or landline bill; DMV registration; insurance bill; W-2 tax form; voter registration; employment or bill payment receipt; letter from Government agency.

The PARENTS/GUARDIANS must provide the following: (a) Government Issued Photo Id (state Driver’s License, state ID card, passport) AND (b) one of any of the following: utility, internet, cable, or landline bill; DMV registration; insurance bill; W-2 tax form; voter registration; employment or bill payment receipt, letter from Government agency.

Resident Address: City Zip

Home phone: Mobile phone: Email:

Warning: Do not sign this form if any of the statements below are incorrect or you will be committing a crime punishable by a fine, imprisonment, or both. PAUSD’s Residency Officer will actively investigate all cases where there is reason to believe that false information may have been provided; this can include home visits. Investigations that reveal a student is not living within PAUSD boundaries will lead to the student’s immediate removal from the school.

Resident Statement

I, (print Resident name) , the owner or lessee of the residence listed above, do solemnly swear

and affirm, and declare under penalty of perjury under the laws of the State of California, that

and their children listed below (names and birth dates), Name of Parents/Guardians

birth date ; birth date Name of Student Name of Student

birth date ; birth date Name of Student Name of Student

all physically reside with me at the above-named address, which is my only residence.

This living arrangement is: Temporary – Duration: Permanent

Resident Phone Number: Best Number to be Reached Signature of Resident

Parent/Guardian Statement We/I, (Parent(s)/Guardian(s) Name(s)), the parents/legal guardians of

(names of students listed in above Resident Statement) do solemnly swear or affirm, and declare under penalty of perjury under the laws of the State of California, that we reside at the address listed above. This living arrangement is: Temporary – Duration: Permanent

Signature of Parent Signature of Parent

Shared Residency Affidavit

1 page of 2

Registration Services 25 Churchill Avenue Palo Alto, CA 94306

Tel. 650-329-3707 Updated 12/18/2017

To be completed by a notary: Resident Signature and Identity

A notary public or other officer completing this certificate verifies only the identity of the individual who signed this document and not the truthfulness, accuracy, or validity of this Shared Residency Affidavit.

State of California, County of Santa Clara

Subscribed and sworn to (or affirmed) before me this day of , 20 , by

(1) (Resident)

proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to be within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ties), and that by his/her/their signature(s) on the instrument, the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

Signature Signature of Notary Public (Place Notary Seal Above)

To be completed by a notary: Parent/Guardian Signature and Identity

A notary public or other officer completing this certificate verifies only the identity of the individual who signed this document and not the truthfulness, accuracy, or validity of this Shared Residency Affidavit.

State of California, County of Santa Clara

Subscribed and sworn to (or affirmed) before me this day of , 20 , by

(1) (Parent(s)/Guardian(s))

proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to be within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ties), and that by his/her/their signature(s) on the instrument, the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

Signature Signature of Notary Public (Place Notary Seal Above)