North Pike School District


This form is a temporary declaration of residence document to be used when parent of guardian cannot provide a lease or mortgage document because they are living with another adult.

The Affidavit of Residence requires that:

1.  The student and the parent/legal guardian live at the address seven (7) days a week.

2.  Further proof of residency may be required during the course of the school year.

3.  Any change of address will revoke this permit.

4.  The District reserves the right to require the renewal of the Affidavit.

5.  The Affidavit will be revoked immediately if any information herein is found to be false.

Personally appeared before me, the undersigned legal authority in and for the jurisdiction aforesaid, the within

named, ______who states under oath and penalty of perjury the following:

(Name of Resident)

1. I reside at ______, which is located within the

(Address of Resident)

North Pike School District.

2. The relationship between ______and Affiant is

(Parent/Legal Guardian’s Name)


3. ______lives in my home full time.

(Student’s Name)

4. The reasons why ______is living with me are

as follows: (Student’s Name)



5. ______is not living with me for the purpose of

(Student’s Name)

attending school in the North Pike School District.

6. I understand that ______will not be allowed to enroll in the

(Student’s Name)

North Pike School District if he/she is living with me for the purpose of attending said School.


Signature of Residency Owner Signature Date


Signature of Parent/Legal Guardian Signature Date

SWORN TO AND SUBSCRIBED before me on this the ____ day of ______, A.D., 20 ____



NOTARY PUBLIC SIGNATURE (Employee of the North Pike School District)

Note: A school district official will verify this residence. If the residence cannot be verified, said

student will no longer be eligible to attend North Pike Schools.