Department of Student Services
MONTGOMERY COUNTY PUBLIC SCHOOLS
Rockville, Maryland 20850
STUDENT RESIDENCY VERIFICATION
INSTRUCTIONS: This form is to be completed by parent or legal guardian. For students transitioning to the next school
level, verication of Montgomery County residency must be presented. Homeless students and students enrolled under
Kinship Care are exempt. Please submit this form to the middle school guidance secretary.
MCPS Form 560-33, 1/09
Student's Legal Last Name Student's Legal First Name Middle Name
/ /
Current School Name Current ID # Mo. Day Yr.
Grade Birth Date
M My child will not be attending MCPS for Grade 9. I understand that he/she will be withdrawn at the end of the school year
(sign and date below).
RESIDENCY
Street Address City
- -
State ZIP Code Home Phone
Proof of Residency—MCPS Regulation JEA-RB, Enrollment of Students, requires a copy of one of the following:
M Current property tax bill M If lease is more than 1 year old, lease and current utility bill
M Current lease M Shared Housing Disclosure Form (MCPS Form 335-74)
Responsible adult living at current address:
Name
Relationship: M Father M Mother M Guardian
M Other
Employer
Work Phone - -
Cell or Beeper # - -
Responsible adult living at current address:
Name
Relationship: M Father M Mother M Guardian
M Other
Employer
Work Phone - -
Cell or Beeper # - -
The information as submitted on this form and on any attachments is accurate, complete and true to the best of my knowledge.
I understand that falsication of any information submitted shall be cause for denial of enrollment. Furthermore, I understand I
am responsible for reporting to the school principal if the student becomes a non-resident of this county and that I am liable for
tuition for any periods that the student may be a non-resident, unless homeless.
/ /
Signature, Parent/Legal Guardian Date
Siblings (Name) Birth date Current School
/ /
/ /
/ /
/ /
