PBSD 1866 (Rev. 5/10/2018)
Affidavit of Residence
THE SCHOOL DISTRICT OF PALM BEACH COUNTY
PLANNING AND INTERGOVERNMENTAL RELATIONS
This form should only be used when there are extenuating circumstances or hardship that prevent a parent or guardian from
being able to provide two (2) proofs of address. Complete and date this form, sign under oath before a notary, and return to
the front office of the school.
Absent an approved alternative method of assignment or reassignment, all students in The School District of Palm Beach
County shall be assigned annually to the school which they are to attend under the authority of the Board and by direction of
the Superintendent, pursuant to School Board Policy 5.01 and Policy 5.011. Students shall be assigned to schools under
these policies based on residence of the student/parent/legal guardian within the attendance boundaries which have been
established by the School Board.
2. a,
OR b,
3. a,
OR b,
I, ( print name of parent/legal guardian/person acting as parent)
am the parent/legal guardian of the following named student(s) (print name(s) of student(s)):
I am an emancipated student (print name)
I am the parent/legal guardian and am currently residing at the address listed below with the above-named
student(s):
I am the emancipated student and am residing at the address listed below:
*The primary residence is defined as the home in which the student(s) spends most of his/her/their time.
Address: *
My contact phone number(s):
4.
5.
This verification is necessary in order for the student(s) named above to attend (print school name):
7.
CHECK EITHER 3a or 3b, THEN ENTER YOUR ADDRESS IN THE ADDRESS BOX BELOW*
Page 1 of 2
1.
What is the extenuating circumstance or hardship that prevents you from providing two (2) proofs of address?
I certify that I do not claim a homestead exemption at any other address and I hereby authorize the school or District
to share my address and related information with other government agencies, such as County Property Appraiser
Offices, for the purpose of verifying the residence. If not, please explain briefly below.
6.
Important Information for Student Athletes -
The student’s ability to participate in athletic programs may be delayed while documentation is being reviewed and
athletic eligibility is being determined by school personnel and/or the Manager for District Athletics.
According to the Florida High School Athletic Association's Operational Bylaws, Article 9:
9.1.2.2 Falsification of Information. A student and/or parent/legal guardian appointed by a court of competent
jurisdiction falsifies information to gain eligibility shall be declared ineligible to represent any member school for a
period of one year from the date of discovery.
PBSD 1866 (Rev. 5/10/2018)
Affidavit of Residence continued
Student Name(s)
Florida Statutes §837.06 provides that whoever knowingly makes a false statement in writing with the intent
to mislead a public servant in the performance of his official duty shall be guilty of a misdemeanor of the
second degree. Additionally a person who knowingly makes a false declaration under penalties of perjury is
guilty of the crime of perjury by false written declaration, a felony of the third degree.
9.
I agree to immediately notify the School District of any future changes in address or living arrangement of
this/these student(s). Under penalties of perjury, I hereby declare that I have read this document and the
above facts are true and correct:
Signature of Parent/Legal Guardian/Emancipated Student Date
STATE OF FLORIDA, COUNTY OF PALM BEACH
Sworn to (or affirmed) and subscribed before me this day of , (year)
by
Who is personally known to me or who produced as
identification
.
Signature of Notary Public - State of Florida
Print, Type, or Stamp Commissioned Name of Notary Public, Commission
Number and Expiration Date
If the student(s) is/are temporarily living with the parent/legal guardian and/or someone else at the address indicated on page
1, see Paragraph 6 of Policy 5.011.
Name, contact information and phone number of Owner/Lessor/Lessee:
I, the Owner, Lessor, or Lessee at the above address, declare that the above named student(s) or emancipated student is/are
living at this address.
Florida Statutes §837.06 provides that whoever knowingly makes a false statement in writing with the intent to
mislead a public servant in the performance of his official duty shall be guilty of a misdemeanor of the second
degree. Additionally a person who knowingly makes a false declaration under penalties of perjury is guilty of the
crime of perjury by false written declaration, a felony of the third degree.
Under penalties of perjury, I hereby declare that I have read this document and the above facts are true and correct.:
DateSignature of Owner/Lessor/Lessee
Page 2 of 2
I understand that falsification of this information may result in the withdrawal of the student(s) from this school and
that falsifying my residence when enrolling the student(s), may be referred to law enforcement for prosecution.
8.
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