BELMONT-REDWOOD SHORES SCHOOL DISTRICT Office of Student Services VERIFICATION OF RESIDENCE FORM Notarized Statement of Property Owner

Instructions for parent or legal guardian: Please complete this form, have property owner and applicant notarize it and return it to your school, along with current original utility bills from TWO different utility companies. Document checks and periodic home visits may be made to verify your residence at this address. Evidence of perjury or providing false information may result in the removal of a student from Belmont-Redwood Shores Schools. Part 1 Property Owner’s Statement (to be completed by Property owner) I declare under penalty of perjury under the laws of California that ____________________________________________ And _________________________________________ reside full time at Child’s Name ________________________________________________________________ within the Belmont-Redwood Shores District Address/City/Zip attendance boundary. Signature of Property Owner or Manager

Address

Telephone

Date

Print Name of Property Owner or Manager Lessee signature if shared residence Telephone Date ____________________________________________________________________________________________________________

Part II Parent/Legal Guardian Statement (To be completed by parent/legal guardian sharing residence) _______________________________________________ have legal custody of Parent/Legal Guardian _______________________________________________ __________________ Name of Student Date of Birth I declare under penalty of perjury under the laws of California that my child and I presently reside full time at ___________________________________________________ This property is registered in the name of Address/City/Zip ____________________________________________________ and is within the school’s attendance boundary. Name of Property Owner ____________________________________________________ Parent Legal Guardian (signature)

___________________________ Date

ACKNOWLEDGEMENT A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.

State of California County of _____________________________) On _________________________ before me, _________________________________________ (insert name and title of the officer) personally appeared ______________________________________________________________, who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature ______________________________

(Seal)

Partial List of Public Notaries

Belmont

RE/MAX Star-Carlmont Associates Drew Morgan, Notary Public 1940 Ralston Avenue (corner of Villa & Ralston) Direct (650) 590-4525 (650) 592-7111

San Mateo

Agency Insurance 25 W. 25th Ave. Patio #8 572-8944