This afdavit form may be used if you are an adult who has assumed responsibility for a pupil and provide the pupil with a xed, night-
time abode, for reasons other than access to the educational programs of the school district.
This form should not be used, however, if you are the natural or adoptive parent of the pupil, have been granted court-ordered custody
or guardianship, or are receiving public aid on behalf of the pupil. For these situations, you are only required to provide documentation
(such as a birth certicate or court order), without the need of an afdavit like this one.
This form is also not required for pupils who are sharing the housing of others due to lack of housing, economic hardship, or similar
reason, or are otherwise homeless as defined in state and federal law. Homeless pupils must be enrolled immediately.
If you have any questions about residency, including homelessness, please contact the Illinois State Board of Education’s Regulatory
Support & Wellness Division at (217) 782-5270.
I, _________________________________, reside at _______________________________________________________________,
which is located within the boundaries of ________________________________________________________________________.
Provide the appropriate information and check each of the following:
I am at least 18 years of age.
I have provided proof in the form(s) of ____________________________________________________________________
that I am a resident of __________________________
I have assumed and exercise responsibility for _____________________________________________________________.
I provide a xed, night-time abode for ____________________________________________________________________.
__________________________________ is not living with me for the purpose of having access to the educational programs
of the school district.
I understand that knowingly or willfully providing false information to a school district regarding the residency of a pupil for
the purpose of enabling that pupil to attend any school in that district without the payment of nonresident tuition is a Class C
I understand that knowingly enrolling or attempting to enroll a pupil in the school of a school district of a tuition free basis
when I know that pupil to be nonresident of the school district, unless the nonresident pupil has a lawful right to attend, is a
Class C misdemeanor.
Signature of Adult
Adult (Print Name)
School District Employee (Signature)
School District Employee (Print Name)
Name of Adult Address
School District
Proof of Residency
School District
Name of Pupil
Name of Pupil
Name of Pupil
ISBE 85-51 (8/18)
100 North First Street
Springeld, Illinois 62777-0001
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