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.
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
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.
My contact phone number(s):
This verification is necessary in order for the student(s) named above to attend (print school name):
CHECK EITHER 3a or 3b, THEN ENTER YOUR ADDRESS IN THE ADDRESS BOX BELOW*
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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.
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:
22.214.171.124 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.