JECA-1

Residency Affidavit

I, ___________________________________________ swear under penalty of perjury* that

Please Print (Parent or Legal Guardian)

________________________________________ lives with me at the following address:

(Student Name & Parent if applicable)

________________________________________ , __________________, NH __________

(Street Address) (City/Town) (ZIP)

***** ***** ***** *****

Name: ________________________________________________________________

I am legally responsible for the above named student. Please check one of the following:

_____ Parent

_____ Custodial Parent

_____ Legal Guardian (Attach Court Order)

_____ Student (Age 18 or over)

_______________________________________________ _____________________

(Parent or Legal Guardian Signature) Date

Signed and attested before me:

____________________ __________________________________________

Date Notary Public

*N.B.: The penalty for perjury is a Class B felony with a maximum sentence of imprisonment not to exceed seven (7) years and/or a fine not to exceed $4,000.

Adopted: February 8, 2007