Affirmation of Residence

Prevention & Student Placement
2500 South State Street Office (385) 646-4660
Salt Lake City, Utah 84115-3110 Fax (385) 646-4697

Granite School District • 2500 South State Street • Salt Lake City, Utah 84115-3110
(385) 646-5000 • www.graniteschools.org

AFFIRMATION OF RESIDENCE

I, ____________, parent/guardian of ____________, do affirm that we are currently living with ____________ whose residence is ____________, and is located in the school boundaries.

It is understood that if we move from this address, we will immediately notify the above-named school and, if our new address falls within the boundaries of a different school, we will no longer be entitled to attend the above-named school unless the student is enrolled under Title VII-B of the McKinney-Vento Homeless Assistance Act.

NOTE: Utah State Law Subsection 53A-2-202 (12), states that submission of misleading information may constitute a violation of the law (76-8-504) and the person doing so may thus be guilty of a class B misdemeanor.

Signature of Parent/Guardian: ____________

State of Utah
County of Salt Lake
Subscribed and sworn to (or affirmed) before me this ____________ day of ____________, 20____ by ____________.

Notary Public

Signature of Residence Holder: ____________ (Residence Holder must provide proof of residency upon registration)

State of Utah
County of Salt Lake
Subscribed and sworn to (or affirmed) before me this ____________ day of ____________, 20____ by ____________.

Notary Public