LIVING WITH ANOTHER FAMILY

							                                LIVING WITH ANOTHER FAMILY
                              (Two families residing in the same home)

Date: ______________________

STUDENT: ___________________________________________________, is currently
                                        Student’s name
Living with his/her parent/legal guardian ______________________________________
                                                                  Please print
at ______________________________________________, Phone ________________,
          Street                         City            St/Zip
the home of ______________________________ relationship to student ___________

and will remain at this address. If the parent/legal guardian moves from the above

address the student must accompany the parent/legal guardian.


We acknowledge that falsifying any of the above information makes us subject to the law
and could result in adverse action.

Parent/Guardian’s signature must be notarized:

_______________________________ Signature: ______________________________
        Parent/Guardian – Print name

                                                JURAT
State of Utah
County of Utah
Subscribed and sworn/affirmed to before me this ________ day of _______________________, 20_____
by _________________________________.
_____________________________________
Notary signature

My Commission expires: _________________
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Homeowner’s signature must be notarized:

_______________________________ Signature: ______________________________
         Homeowner – Print name

                                                JURAT
State of Utah
County of Utah
Subscribed and sworn/affirmed to before me this ________ day of _______________________, 20_____
by _________________________________.
____________________________________
Notary signature

My Commission expires: _________________