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Chesterfield County Public Schools

Proof of Residency (8/06) AAA-1418 revised

CHESTERFIELD COUNTY PUBLIC SCHOOLS

Parents, legal guardian, or person acting in place of the parent, please complete this form, have it notarized, and

return it to the school serving your attendance zone.

Date: ________________ School: ___________________________________ For School Year: __________

I, _____________________________________, Parent, legal guardian, person acting in place of parent*,

own/rent/lease housing and reside with: (Student’s name)________________________________________________ at:

(Street Address) ___________________________________________________________________________________

(City/County) ______________________________________________, (State) _VA _ (Zip) ___________________

Telephone: (Home) _____________________ (Work) _____________________ (Cell) __________________

For the purpose of establishing residency in Chesterfield County, the parent, legal guardian, or person acting in place of

the parent shall provide one of the following documents in the name of that individual:

1. lease for a period of at least one year of a residence located in Chesterfield;

2. deed to a residence located in Chesterfield;

3. contract or lease free of contingencies to occupy a Chesterfield residence within two months of the date

of enrollment;

4. residence manager’s letter on company letterhead stating residence is a corporate residence located in

Chesterfield; or

5. weekly receipts for temporary residence in a hotel or motel for up to 60 days (will require renewal or

evidence of more permanent residency within 60 days of enrollment).

*When the student is living with someone other than his/her natural parent or a parent by legal adoption, the

person with whom the student is living shall provide: (1) a personal written statement explaining the reasons

why the student cannot be cared for by the parents and (2) Independent verification or substantiation of the

family circumstances from an appropriate professional or agency such as proof of incarceration, doctor's

statement, or investigative statement by child protective services, etc.

The sufficiency of the documentation provided with each enrollment application shall be determined by the

school division administration in accordance with controlling policy and regulations.

Certification

I hereby certify that all of the above information is true and correct, and I agree and understand that any

falsification of information may result in the immediate removal of my child/children from the Chesterfield County Public

Schools. I also agree and understand that any falsification of information will make me responsible for paying full

nonresident tuition for my child/children from the date of enrollment in the Chesterfield County Public Schools. I further

understand that should a principal have reason to believe that my residency status has changed, I may be required to submit

a new proof of residency and that failure to do so may result in the immediate removal of my child/children from Chesterfield

County Public Schools. I hereby agree to release this information to be verified. WARNING: Providing false information for

school enrollment purposes is a criminal offense. VA Code 22.1-264.1.

________________________________________ ________________

Signature of Parent/Guardian/Custodian Date

In the City/County of ___________________________________ in the Commonwealth of Virginia, the statements

hereon have been sworn to and subscribed before me this _____ day of ________________, in the year _______.

Witness my hand and official seal: _________________________________________

Notary Public

My commission expires: ______________

Date