.05 Affidavit Form.

A. The affidavit shall be in the following form:

I, the undersigned, am 18 years old or older and competent to testify to the facts and matters set forth in this statement.

_________________ (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

The name and last known address of the child's parent(s) or legal guardian is:




My kinship relation to the child is _________________________________

My address is

Street Apt. No.

City State Zip Code

I assumed informal kinship care of this child for 24 hours a day and 7 days a week on __________ (day/month/year).

The name and address of the last school that the child attended is:



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 public school or 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.

I solemnly affirm under the penalties of perjury that the contents of the foregoing statement are true to the best of my knowledge, information, and belief.

Signature of affiant


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 prorated share of tuition for the time the child fraudulently attends a public school in the county.

B. Each local school system shall:

(1) Make affidavit forms, with attached instructions, available free of charge at the offices of each county board of education; and

(2) Advise inquirers that affidavit forms are also available at the local department of social services and the local area agency on aging.