AFFIDAVIT OF RESIDENCE
GEORGIA CYBER ACADEMY
Full Name of Enrolling Parent(s)/Guardian(s): _________________________________________________________
Last Name First MI
Current Address: ________________________________________________________________________________
Street Number Street Name City/County
How long have you resided at the address? ________________________
Child(ren) residing at the Address
The undersigned, Parent/Guardian, first being duly sworn, deposes and states that he/she is the parent/guardian of the child(ren)
listed above, and that said child(ren) live with the undersigned, and that the parent(s)/guardian(s) resides at the address with child(ren)
and the undersigned are bona fide full time residents of the recorded address.
The undersigned further agrees that he/she will notify Georgia Cyber Academy if the parent and/or student ever terminate the above
residence while the student is enrolled with Georgia Cyber Academy. If it is determined that the student does not live in the above
residence the legal guardian will be responsible for providing an updated proof of residency (Utility Bill or lease agreement).
Please note that a proof of residence for the Owner/Landlord/Renter must be provided with this form.
*False swearing is a violation of the laws of the State of Georgia, punishable by a fine of not more than $1,000, or be
imprisonment for not less than one nor more than five years, or both. Georgia Code (O.C.G.A. 16-10-71).
________________________________________
Print Parent/Guardian Name
Signature of the Parent/Guardian
_____________________
The undersigned, Owner/Landlord/Primary Renter, first being duly sworn, deposes and states that he/she is the legal owner, landlord
or renter of the property listed above. The persons recorded within this document reside with me full time and have my consent to
live at the address recorded above. I understand that if a child(ren) are/is enrolled in Georgia Cyber Academy under falsified
information is illegally enrolled and may be withdrawn if verification of residence is unfounded. I further understand that making false
statements or submitting false documentation and false swearing is a violation of O.C.G.A. 16-10-20 and/or 16-10-71 of the criminal
laws of the State of Georgia and punishable by a fine or by imprisonment.
________________________________________
Print Owner/Landlord/Primary Renter Name
Signature of the Owner/Landlord/Primary Renter Name
_____________________
