Millbury Public Schools Sworn Statement of Residency This form is

Millbury Public Schools
Sworn Statement of Residency
This form is to be completed during enrollment by a student’s parent or legal guardian. This form
must be submitted as a Sworn Statement of Residency and documented proof of residency for
each child enrolled in the school district. The Millbury Public Schools reserves the right to
request a new form if non-residency is suspected.
Student’s Name:__________________________________________________________
First Name
Middle Initial
Last Name
Date of Birth:_____________Grade Level:_____________Phone #:________________
Physical Street Address of Residence (please note that a PO Box is not acceptable as a residential
address.)
Address:________________________________________________________________
# and Street Name
Town
State
Zip Code
I declare, under the penalty of perjury, that this student resides at the above address. I also
agree to notify the Millbury Public School District immediately when the residency changes.
I understand that a new Sworn Statement of Residency and new documented proof of residency
must be submitted when the residency changes. Failure to notify the district or falsification of
any information or documents required for residency verification may result in revocation of a
student enrollment and or civil action, resulting from fraud, negligent misrepresentation and
negligence.
Parent/Legal Guardian Signature:__________________________________ Date:___________
Print Name:____________________________ Relationship to Student:__________________
Documented Proof Of Residency Requirements:
If you are a current resident in the Town of Millbury, the following must be provided:
1. A signed rental/lease agreement, a signed real estate sales contract, or a signed settlement
statement/deed including the name and address of the parent/guardian; AND
2. A utility bill (gas/electric/water) for the current month, including the name and address of
the parent/guardian
If you share a home with a relative that resides in the Town of Millbury, the following must be
provided:
1. The relative’s proof of legal residence; AND
2. Documentation verifying proof of the parent/guardian residing at the address, such as a
driver’s license, checking account, credit card statement, voter registration, paycheck etc.
A representative of the Millbury Public Schools may periodically visit the address given to verify
residency. The actual address must be the location where the parent/guardian and student live.
An individual who owns property in the Town of Millbury, but does not reside in the
district, is not considered a resident.
11/2011