Form Pbsd 1543 – Fill Out and Use This PDF

THE SCHOOL DISTRICT OF PALM BEACH COUNTY

DEPARTMENT OF LEGAL SERVICES

Affidavit of Person Acting as Parent

The purpose of this form is to verify the status of a person acting as parent pursuant to School Board Policy 5.011. Complete this affidavit and submit to the student's school. Only notarized forms will be accepted. This form does not apply to homeless students. Submittal of this form does not guarantee enrollment at this school. The person acting as parent has the burden to show that the students' residence is not incident to the students' eligibility to enroll in a particular school's boundary and is due to extenuating circumstances.

I, (name of guardian/person acting as parent)

am acting as parent for the following named child or children (print name of child or children):

I(person acting as parent/guardian) am currently residing with the above-named child(ren) at the residential address below in Palm Beach County, and this is the child(ren)'s primary residence. The primary residence is defined as the home in which the child(ren) spends most of his/her (their) time. Exceptions may include certain court-approved agreements for Shared Parental Responsibility (street/city/zip code):

This verification is necessary in order for the child or children named above to attend (school name):

Pursuant to Florida Statutes §1000.21, I qualify as a person acting as "Parent" under the following circumstance (check one only)

Guardian of a student (legal guardianship papers are required)

Person in a parental relationship (Proof Required - written notarized statement from the natural parent or guardian explaining why and how this person is acting as a parent. Provide address and telephone number of natural parent below.)

Person exercising supervisory authority over a student in place of a parent (Proof Required - written notarized statement from the natural parent or guardian explaining why they are unable to perform in a parental role is required, except as stated within Policy 5.011. Provide address and telephone number of natural parent below.)

Note: If the natural parent or guardian is unavailable (such as having abandoned the child, incarceration, or living in a foreign country), the requirement for a notarized statement is waived.

Address of natural parent:

Natural parent telephone number(s):

I understand that falsification of this information may result in the withdrawal of my child(ren) from this school and that falsifying my residence when enrolling my child(ren), may be referred to law enforcement for prosecution.

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.

I agree to immediately notify the School District of any future changes in address or living arrangement of this child(dren). Under penalties of perjury, I hereby declare that I have read this document and the above facts are true and correct.

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Signature of Person Acting as Parent/Guardian

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

Interoffice Use Only: Area Office Approval Required

Yes

No

Approval Granted

Yes

No

NA

Signature of Area Office's Superintendent

Date

PBSD 1543 (Rev. 6/25/2012) RECORD COPY - School COPY- Person Acting as Parent/Guardian