Shared Domicile Form – Fill Out and Use This PDF

BALTIMORE COUNTY PUBLIC SCHOOLS

OFFICE OF PUPIL PERSONNEL SERVICES

SHARED DOMICILE DISCLOSURE FORM

The undersigned do hereby attest that the parent(s)/guardian(s) of the child(ren) listed below are residing at the following address:

______________________________________________ ______________________________________________ ____________________

Street AddressCity, State, Zip CodeHome Phone Number

and request that the following school-aged child(ren) residing at the same address be permitted to enroll in the Baltimore County Public Schools for the school year 20____ - 20_____ (Do not list children of homeowner/leaseholder):

Name of Student	Date of Birth	School	Grade
______________________________________	____________	__________________________________	____________
______________________________________	____________	__________________________________	____________
______________________________________	____________	__________________________________	____________

It is understood that the information provided by the undersigned is accurate. Any attempt to falsify the above information shall result in withdrawal of the student(s), and the appropriate tuition charge shall be assessed for each student falsely enrolled in the Baltimore County Public Schools. Tuition fees are subject to revision by the Baltimore County Board of Education.

The above-named student(s) will be permitted to enroll in the Baltimore County Public Schools as long as the student(s) and parent(s)/guardian(s) are domiciled at the above-stated address. If a change in domicile occurs, the resident (homeowner/ leaseholder) and parent(s)/guardian(s) MUST notify the school(s) immediately. If it is determined that false information has been provided or a change in domicile occurs and the school(s) is/are not notified, both the resident (homeowner/leaseholder) and parent(s)/guardian(s) whose signatures appear below shall be liable for the assessed tuition, in accordance with Board of Education Policy and Superintendent’s Rule 5150, STUDENTS: ENROLLMENT AND ATTENDANCE.

It is further understood that in accordance with Superintendent’s Rule 5150, the resident (homeowner/leaseholder) will provide proof of property ownership or current lease, and the parent(s)/ guardian(s) will provide a photo identification and three (3) current documents proving domicile at the above-stated address. Residency verification must be renewed each year that the student(s) and parent(s)/guardian(s) live in a shared domicile living arrangement.

I solemnly affirm under the penalties of perjury that the contents of the foregoing are true to the best of my knowledge, information, and belief. Furthermore, I have received and read copies of Policy and Rule 5150.

_______________________________________________	_________________________________________________
Signature of Resident (Owner/Leaseholder)	Signature of Parent(s)/Guardian(s) of Student(s)
_____________________________________________________	_______________________________________________________

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DECISION: ______ Approved ______Denied	_______________________________________________________ Date_______________
	Signature of Residency Assistant/Pupil Personnel Worker

If approved, enrollment is for the 20____ - 20____ school year only, and only if the parent(s)/guardian(s) and child(ren)

named herein reside at the address provided on this DISCLOSURE FORM. A new DISCLOSURE FORM must be filed each school year.

APPEALS: Must be made in writing to the Residency Liaison acting as the designee of the Executive Director of Student Support Services, Baltimore County Public Schools, 9610 Pulaski Park Drive, Suite 219, Baltimore, Maryland 21220, within 10 school days of the date of decision. A copy of this DISCLOSURE FORM signed by the residency assistant/pupil personnel worker must accompany the appeal.

Rule 5150

Form A-081407