By my signature, I hereby attest that Susan Ludington is by g5z7RL

VIEWS: 21 PAGES: 1

									STATE OF _____________________________
and
COUNTY OF ___________________________
or
COUNTRY OF __________________________



The attached Form I, “Custodial Statement and Agreement: Divorce, Separation, or

Abandonment” regarding the residence of __________________________, was signed
                                                  (name of student)

by his/her parent/custodian, ____________________________, before me, a Notary

Public, on the ______ day of ________________________, 20___.




_______________________________________
Signature

_______________________________________
Printed Name

County of Residence: _____________________________

Commission Expires: __________________

								
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