CERTIFICATE OF SUBSTITUTE CARETAKER
___________________________being first duly sworn on oath, disposes and states that I am of legal age and under no mental disability.
I further state that I am a resident of the State of Minnesota, County of Dakota and currently living at __________________________________ in the Independent School District No. 196.
I state that student _________________________________, age ________ is living with me and under my care and support and that I provide the financial, emotional, medical, food, clothing, shelter, etc. for said student, and that said student is not living in the District solely to receive a free education.
I state that I am or will be eligible to claim said student as a dependent under the rules of the
Internal Revenue Service and that I am the one to be notified in case of any emergency or any communication with the School District.
To the best of my knowledge the student’s parents or guardian are as follows:
Parents or Guardian:
____________________________________________________________________________
Father
____________________________________________________________________________
Address Telephone
_____________________________________________________________________________
Mother
_____________________________________________________________________________
Address Telephone
_____________________________________________________________________________
Guardian (if any) Address Telephone No.
_______________________________________
Parent Name
________________________________
Affiant
_______________________________________
Parent Signature
Subscribed and sworn to before me this _______ day of _____________________, 2007.
___________________________________________
Notary Public