Fill and Sign the Tx Affidavit Form

1 Affidavit of Guardianship and Residency THE STATE OF TEXAS COUNTY OF ___________________ BEFORE ME, the undersigned authority, on this day personally appeared _______________________ (Name of Guardian), who swore or affirmed to tell truth, and stated as follows: My name is ___________________ (Name of Guardian). I am over the age of 18 and capable of making this Affidavit. I attest that the following facts are based on my personal knowledge and that they are true: 1. The following address where I reside is located within the boundaries of the ____________________ (Name) School District. A. I currently reside at ______________________________________ ________________________________ (street address, city, state, zip code). B. My phone number at said address is _________________; my work phone number is ________________; and my cell phone number is _____________. 2. The Student, _______________________ (Name of Student) lives and resides with me at the above address and is ______ years old. 3. This Student, hereinafter sometimes called Child has come into my custody under the following circumstances: [e.g., The Child’s Mother is ill and cannot care for the Child, and his/her Father cannot be located. I am the Child’s Aunt, e.g., the sister of the Child’s Mother. The Child came to live with me in (year) after his/her Mother became ill and has been living with me ever since] . Documentation supporting these facts are attached to this Affidavit. 4. I have not undertaken court action to have myself appointed as a legal guardian for this Child. 5. I have voluntarily assumed a parental role with regard to this Child. 6. I have undertaken to enroll this Child in ________________________ (Name of School) . Since no legal guardian exists to assume parental responsibilities for this Child, I voluntarily agree to accept that role in a de facto capacity for the following purposes: A. To receive and discuss the Child’s class work with appropriate School District personnel. 2 B. To examine and receive copies of the Student’s records and report cards from the School District. C. To give permission for the Child’s participation in various activities such as but not limited to field trips and travel for extracurricular activities. D. To be notified in emergencies and to give consent for the medical care and treatment of this Child. E. To be notified and consulted concerning issues including attendance and tardiness. F. To represent the Child in any disciplinary actions initiated by the District. G. To be notified of potential releases of information regarding the Child under the Family Educational Rights and Privacy Act. H. To accept such further parental responsibilities as may arise in connection with the Child’s enrollment and attendance in _______________________ (Name of School) . I understand that this Affidavit does not affect legal guardianship, and that court action for this purpose would be required. I further understand that I must notify ___________________ (Name of School) when the Child ceases to reside with me or when any other person obtains legal guardianship of the Child. FALSIFICATION OF INFORMATION ACKNOWLEDGEMENT I declare that I have provided no false information to the _____________ ________________ (Name of School) regarding my family residency. I understand that falsifying this sworn affidavit is a criminal offense (Perjury) under Section 37.01 of the Texas Penal Code, which is a Class A misdemeanor punishable up to one (1) year of confinement in jail; a fine not to exceed $2000.00; or both such fine and imprisonment. Another criminal offense for falsifying this residency information is a violation of Texas Penal Code 37.10: Tampering with a Government record . I understand that a person who enrolls a student in ____________________ (Name of School) based on false information may be liable to the School District for the period during which the ineligible student is enrolled, for the greater of: 1. The maximum tuition fee that may be charged under 25.038 of the Education Code; or 2. The amount the School District has budgeted for the student as maintenance and operating expenses. The regular tuition rate is $________ per school day for 20____ -- 20_____ school year. 3 I understand that the Child will be administratively withdrawn from _______________________ (Name of School) if it is determined that I have enrolled the Child based on false information. I also understand that _________________________ (Name of School) reserves the right to investigate claims of residence under the ____________________ (Name of School) administrative guidelines as permitted by the Texas Education Code and may conduct a home visit to verify actual occupancy. ____________________________________ (Signature of Guardian) STATE OF TEXAS § COUNTY OF ____________________§ BEFORE ME, the undersigned authority, on this day personally appeared ____________________ (Name of Guardian), known to me by _____________________ (Guardian signing form) (ID, Passport, etc.) to be the person whose name is subscribed to the foregoing instrument and acknowledged to me that he/she executed that same for the purposed and consideration therein expressed. GIVEN UNDER MY HAND, and seal of this office this ______day of __________________, 20_____A.D. ________________________________ Notary Seal Here Notary Public, State of Texas My commission expires: _______________________******************************************************************************************* NOTE: Attach a copy of your TDL/ID, and current utility bill, AND current lease or mortgage statement with this original certified packet. Then make a copy of the original packet plus attachments and bring both packets to the Department of Safe & Secure Schools located at _________ ________________________________ (street address, city, state, zip code). ********************************************************************************************