STATE OF

) ) §§ )

COUNTY OF

AFFIDAVIT OF RESIDENCY (To be completed by Property Owner/Landlord/Leaseholder)

I,

,

being

duly

sworn

state

on

oath

that

I

am

the

(print your name)

________________________ of the residence known as

; (address of property)

(Property Owner/Landlord/Leaseholder)

and that I personally know ____________________________________________________________, [print name(s) of all occupant(s)]

and that said persons: rent the above-described premises from me (written Rental Agreement  Yes  No) (if ‘Yes’ please provide a copy of Agreement)

reside with me at the above-described premises

Further, I attest that __________________________________________________________________ (print names of all occupants)

have made the above-described premises their temporary home and that it is known to me that they physically reside at the above-described premises on a regular and continuous basis, since _________________________, 20____. Tenant/occupant is responsible for the following utilities:  Gas

 Electric

 Water  Other

Signature of Property Owner/Landlord/Leaseholder

NOTICE Only pupils who are eligible by statute may enroll tuition-free in the schools of the District. A person who knowingly or willfully presents to any representative of the District any false information regarding the residency of a pupil for the purpose of enabling that pupil to attend any school of the District without payment of a nonresident tuition charge shall be guilty of a Class C misdemeanor. 105 ILCS 5/10-20.12b. I declare that I have read the above Notice and that the information I have provided is true and correct. Signature of Property Owner/Landlord/Leaseholder

SUBSCRIBED and SWORN to before me this ____ day of , 20____.

Notary Public