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Residency_Affidavit

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					_______________________________________________________
675 E Broad St., Bethlehem, PA 18018       610-868-2971      Fax: 610-868-1446    www.lvpa.org



   LEHIGH VALLEY CHARTER HIGH SCHOOL FOR THE PERFORMING ARTS

                                       RESIDENCY AFFIDAVIT

   1. PART ONE TO BE COMPLETED BY RESIDENT HOMEOWNER/TENANT

I/We _____________________________________________________________ attest that all
                      (Homeowner/Tenant)
Information provided herein is correct and current. I/We understand that if residency shall

change for any reason it is the responsibility of the resident to notify Lehigh Valley Charter High

School for the Performing Arts (“Charter School”) and amend the Residency Affidavit. Any

false statements can and may be punishable by law.

I/We currently reside at:

(address) ______________________________________________________________________

(phone) ________________________________________.

I hereby verify my residency by providing one or more, pursuant to Charter School request, of

the following:

                 Utility, Property Tax or Credit Card Bill

                 Pa. Department of Transportation identification or driver’s license

                 Pa. Department of Transportation vehicle registration

                 Copy of paycheck stub with name and address of employee and employer

                 Property lease

                 Property deed

                 Proof of auto insurance with name and address

                 Government Agency Identification Card
I/We hereby state that __________________________________________ are residing at
                         (Name of Parent(s)/Guardian(s) and Students)
my/our above-stated residence.

I/We grant Charter School permission to investigate the information I have presented in this

statement by discussing the presented information with all appropriate parties, as necessary to

confirm factual accuracy.

I/We recognize the following:

       NOTWITHSTANDING ANY OTHER PROVISION OF LAW TO THE
       CONTRARY, A PERSON WHO KNOWINGLY PROVIDES FALSE
       INFORMATION IN A SWORN STATEMENT FOR THE PURPOSE OF
       ENROLLING A CHILD IN A SCHOOL DISTRICT (OR CHARTER SCHOOL
       TO THE EXTENT PERMITTED BY LAW) FOR WHICH THE CHILD IS NOT
       ELIGIBLE COMMITS A SUMMARY OFFENSE AND SHALL, UPON
       CONVICTION FOR SUCH VIOLATION, BE SENTENCED TO PAY A FINE OF
       NO MORE THAN THREE HUNDRED DOLLARS ($300) FOR THE BENEFIT
       OF THE SCHOOL DISTRICT (OR CHARTER SCHOOL TO THE EXTENT
       PERMITTED BY LAW) IN WHICH THE PERSON RESIDES OR TO PERFORM
       UP TO TWO HUNDRED FORTY (240) HOURS OF COMMUNITY SERVICE,
       OR BOTH. IN ADDITION, THE PERSON SHALL PAY ALL COSTS AND
       SHALL BE LIABLE TO THE SCHOOL DISTRICT (OR CHARTER SCHOOL
       TO THE EXTENT PERMITTED BY LAW) FOR AN AMOUNT EQUAL TO THE
       COST OF TUITION CALCULATED IN ACCORDANCE WITH SECTION 2561
       OF THE PUBLIC SCHOOL CODE DURING THE PERIOD OF ENROLLMENT.


I VERIFY THAT STATEMENTS MADE IN THIS AFFIDAVIT ARE TRUE AND

CORRECT AND THAT FALSE STATEMENTS HEREIN MADE ARE SUBJECT TO

THE PENALTIES UNDER THE LAW REGARDING SWORN FALSIFICATIONS.

HOMEOWNER/TENANT: _______________________________________________________

Address: _______________________________________________ Phone: ________________

Sworn and subscribed to before me this _________ day of ____________________ 2011.

Notary Public ____________________________________________

				
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