Address Change

Albany Unified School District

Declaration of Residency

Aeries Date Received:

I, (parent’s name) declare under the penalty of perjury under the laws of the State of California that the residency information provided below is true and correct. 1. Enter the name(s) of current and new student(s) in your household that reside in Albany. 2. Attach proof of Albany residency: current proof of home ownership/rental or lease agreement AND 3. Two (2) current documents (within 45 days) with address imprinted: PG&E bill, EBMUD bill, Payroll check stub, bank statement, voter registration, car insurance with/car registration, or correspondence from a government agency (UC Village residents only need to provide most recent CalCentral Rental Receipt).

Enrollment Year: 20___ - ___ Student Name:

Date of Birth:

Grade Entering: Current School:

Student Name:

Date of Birth:

Grade Entering: Current School:

Student Name:

Date of Birth:

Grade Entering: Current School:

Student Name:

Date of Birth:

Grade Entering: Current School:

Address:

Albany, CA 94706

Home Phone:

Mobile Phone:

Work Phone:

Email:

Landlord Name: if applicable

Phone:

Email:

I certify that my child and I are residents of the city of Albany. If residence verification efforts determine that we do not reside in Albany, I realize that my child will be dropped from enrollment and returned to his/her district of residence within five (5) days. I understand that I must notify the school district within three (3) days if we move out of the Albany City area. At that time, I may apply for an Inter-District Permit, which, if approved, would allow my child to continue in the Albany schools for the remainder of the current school year. __________________________________________ Signature of Parent/Guardian Date

Relationship to Student(s)