|CHILD WELFARE & ATTENDANCE
East Baton Rouge Parish Schools
1120 Government Street
Baton Rouge, LA 70802
STATE OF LOUISIANA
PARISH OF EAST BATON ROUGE
BEFORE ME, the undersigned notary, personally came and appeared:
__________________________________ (full name), called “Affiant,” a person of the age of majority whose permanent mailing address is: (legal custodian of student)
Who did swear before me, upon his/her oath or affirmation, that:
Affiant has been advised and is aware that this Affidavit is being provided to officials of the East Baton Rouge School Board for purposes of admitting a student to the East Baton Rouge Parish School System.
Affiant is advised and is aware that the making of intentionally false statements in this Affidavit may expose him/her and the residency owner to prosecution for false swearing under R.S. 14:125 or other applicable laws of the State of Louisiana.
With the foregoing understanding and awareness of the consequences of giving false information, Affiant attests that:
Affiant is the parent/legal guardian of ____________________________________ (student’s name).
who is temporarily residing with ____________________________________ (name of homeowner)
and is requesting admission to _________________________________________ (name of school).
Affiant currently resides at: ________________________________________________________
(Home owner must be present ________________________________________________________
and initial swearing that this ________________________________________________________
information is correct).
Affiant has resided at the above address for _______________________ (how long at this residence).
__________________________________(student’s name) actually resides at the above address
with legal guardian. This means the student eats most of his/her meals. Sleeps, and keeps his/her
personal belongings at this address. ___________________________ (student’s name) has resided
at address for _____________________ (how long at this residence).
Affiant’s previous address was: ________________________________________________________
The full name and residence address of the student’s parent is given as:
If applicable: Affiant has court ordered custody or court ordered legal guardianship of
_____________________________(student’s name), under the court order attached to this Affidavit.
(Affiant is to attach the court order giving custody or legal guardianship).
If the student’s residence changes, Affiant will notify the principal or his/her designee of the change, in writing, within ten (10) days of the change of residence.
All parties have carefully completed and read this Affidavit and attest to the truth of all the information
provided. This document is valid for one year. It will expire on the last day of the current school year.
To enable Child Welfare and Attendance to verify residence, Affiant consents to an inspection and view of
of the residence herein identified as the student’s residence to ensure that the averments of the affidavit
are true and correct. Said inspection will be permitted upon reasonable notice by Child Welfare &
AFFIANT AND HOMEOWNER’S SIGNATURE: WITNESSES:
Sworn to and subscribed before me, upon oath or affirmation, on this ______________day of __________.
20_______, at __________________, Louisiana.
NOTARY PUBLIC Commission Expiration